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Plute T, Bin-Alamer O, Mallela AN, Kallos JA, Hamilton DK, Pollack IF, Lunsford LD, Friedlander RM, Abou-Al-Shaar H. A comprehensive evaluation of career trajectories of the American Association of Neurological Surgeons William P. Van Wagenen fellows. World Neurosurg X 2024; 23:100365. [PMID: 38595674 PMCID: PMC11002291 DOI: 10.1016/j.wnsx.2024.100365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
Objective To elucidate the current academic, demographic, and professional factors influencing the career trajectories of the American Association of Neurological Surgeons (AANS) William P. Van Wagenen (VW) fellows while also identifying trends that may influence future fellow selection. Methods Fifty-five VW fellows were identified from 1968 to 2022 from the AANS website, along with corresponding institutions, countries, and continents of study. Additional variables such as age at selection, accruing additional degrees, neurosurgical subspecialty, the number of publications at the time of selection, funding, and h-index were collected from various publicly available sources. Results Eighty-five percent of VW fellows were male and had a mean age of 34 ± 2.4 years. Ninety-one percent of fellows chose to study in Europe, and 40% had earned additional degrees. Univariate linear regression demonstrated a positive relationship between the year of selection and both age at selection (p = 0.0094) and the number of publications at hire (p < 0.001), while logistic regression revealed that more recently selected fellows were less likely to study in Europe (p = 0.037) and be of the white race (p = 0.0047). Logistic regression also exhibited a positive trend between the year of selection and both the likelihood that the VW fellow was currently enrolled in another fellowship (p = 0.019) and possessed additional degrees (p = 0.0019). Females were shown to have fewer publications at hire compared to males (p = 0.04). Conclusions Most Van Wagenen fellows are academically productive members of the neurosurgical community. Increased attention is likely to be placed on both academic, research, and individualized factors when selecting future fellows.
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Affiliation(s)
- Tritan Plute
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arka N. Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Justiss A. Kallos
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - D. Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ian F. Pollack
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert M. Friedlander
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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2
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Bin-Alamer O, Qedair J, Abou-Al-Shaar H, Mallela AN, Balasubramanian K, Alnefaie N, Abou Al-Shaar AR, Plute T, Lu VM, McCarthy DJ, Fields DP, Agarwal N, Gerszten PC, Hamilton DK. Surgical intervention ≤ 24 hours versus > 24 hours after injury for the management of acute traumatic central cord syndrome: a systematic review and meta-analysis. J Neurosurg Spine 2024; 40:653-661. [PMID: 38335527 DOI: 10.3171/2023.11.spine23789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 11/16/2023] [Indexed: 02/12/2024]
Abstract
OBJECTIVE The objective was to evaluate the efficacy, outcomes, and complications of surgical intervention performed within 24 hours (≤ 24 hours) versus after 24 hours (> 24 hours) in managing acute traumatic central cord syndrome (ATCCS). METHODS Articles pertinent to the study were retrieved from PubMed, Scopus, Web of Science, and Cochrane. The authors performed a systematic review and meta-analysis of treatment procedures and outcomes according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines. RESULTS Seven articles comprising 488 patients were included, with 188 (38.5%) patients in the ≤ 24-hour group and 300 (61.5%) in the > 24-hour group. Significant differences were not found between groups in terms of demographic characteristics, injury mechanism, spinal cord compression level, neuroimaging features, and the American Spinal Injury Association (ASIA) motor score at admission. Both groups had a similar approach to surgery and steroid administration. The surgical complication rate was significantly higher in the > 24-hour group (4.5%) compared to the ≤ 24-hour group (1.2%) (p = 0.05). Clinical follow-up duration was similar at 12 months (interquartile range 3-36) for both groups (p > 0.99). The ≤ 24-hour group demonstrated a not statistically significant greater improvement in ASIA motor score, with a mean difference of 12 (95% CI -20.7 to 44.6) compared to the > 24-hour group. CONCLUSIONS The present study indicates potential advantages of early (≤ 24 hours) surgery in ATCCS patients, specifically in terms of lower complication rates. However, further research is needed to confirm these findings and their clinical implications.
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Affiliation(s)
- Othman Bin-Alamer
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jumanah Qedair
- 2College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Hussam Abou-Al-Shaar
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arka N Mallela
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Nada Alnefaie
- 4Department of Adult Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Tritan Plute
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Victor M Lu
- 6Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida
| | - David J McCarthy
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daryl P Fields
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nitin Agarwal
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Peter C Gerszten
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - D Kojo Hamilton
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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3
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Bin-Alamer O, Abou-Al-Shaar H, Singh R, Mallela AN, Legarreta A, Bowden G, Mathieu D, Perlow HK, Palmer JD, Elhamdani S, Shepard M, Liang Y, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad Eldin R, Elazzazi AH, Warnick RE, Gozal YM, Daly M, McShane B, Addis-Jackson M, Karthikeyan G, Smith S, Picozzi P, Franzini A, Kaisman-Elbaz T, Yang HC, Hess J, Templeton K, Zhang X, Wei Z, Pikis S, Mantziaris G, Simonova G, Liscak R, Peker S, Samanci Y, Chiang V, Kersh CR, Lee CC, Trifiletti DM, Niranjan A, Hadjipanayis CG, Lunsford LD, Sheehan JP. Local control and survival after stereotactic radiosurgery for colorectal cancer brain metastases: an international multicenter analysis. J Neurosurg 2024; 140:1233-1242. [PMID: 37948682 DOI: 10.3171/2023.8.jns231231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/18/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE The goal of this study was to characterize local tumor control (LC), overall survival (OS), and safety of stereotactic radiosurgery for colorectal brain metastasis (CRBM). METHODS Ten international institutions participating in the International Radiosurgery Research Foundation provided data for this retrospective case series. This study included 187 patients with CRBM (281 tumors), with a median age of 62 years and 56.7% being male. Most patients (53.5%) had solitary tumors, although 10.7% had > 5 tumors. The median tumor volume was 2.7 cm3 (IQR 0.22-8.1 cm3), and the median margin dose was 20 Gy (IQR 18-22 Gy). RESULTS The 3-year LC and OS rates were 72% and 20%, respectively. Symptomatic adverse radiation effects occurred in 1.6% of patients. In the multivariate analysis, age > 65 years and tumor volume > 4.0 cm3 were significant predictors of tumor progression (hazard ratio [HR] 2.6, 95% CI 1.4-4.9; p = 0.003 and HR 3.4, 95% CI 1.7-6.9; p < 0.001, respectively). Better performance status (Karnofsky Performance Scale score > 80) was associated with a reduced risk of tumor progression (HR 0.38, 95% CI 0.19-0.73; p = 0.004). Patient age > 62 years (HR 1.6, 95% CI 1.1-2.3; p = 0.03) and the presence of active extracranial disease (HR 1.7, 95% CI 1.1-2.4; p = 0.009) were significantly associated with worse OS. CONCLUSIONS Stereotactic radiosurgery offers a high LC rate and a low rate of symptomatic adverse radiation effects for the majority of CRBMs. The OS and LC favored younger patients with high functional performance scores and inactive extracranial disease.
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Affiliation(s)
- Othman Bin-Alamer
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hussam Abou-Al-Shaar
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Raj Singh
- 2Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Arka N Mallela
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Legarreta
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Greg Bowden
- 3Department of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - David Mathieu
- 4Department of Neurosurgery, Université de Sherbrooke, Quebec, Canada
| | | | - Joshua D Palmer
- Departments of5Radiation Oncology and
- 6Neurosurgery, The James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | - Yun Liang
- 8Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Ahmed M Nabeel
- 9Gamma Knife Center, Nasser Institute Hospital, Cairo, Egypt
- 10Department of Neurosurgery, Benha University, Benha, Egypt
| | - Wael A Reda
- 9Gamma Knife Center, Nasser Institute Hospital, Cairo, Egypt
- Departments of11Neurosurgery and
| | - Sameh R Tawadros
- 9Gamma Knife Center, Nasser Institute Hospital, Cairo, Egypt
- Departments of11Neurosurgery and
| | - Khaled Abdelkarim
- 9Gamma Knife Center, Nasser Institute Hospital, Cairo, Egypt
- 12Clinical Oncology, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- 9Gamma Knife Center, Nasser Institute Hospital, Cairo, Egypt
- Departments of11Neurosurgery and
| | - Reem Emad Eldin
- 9Gamma Knife Center, Nasser Institute Hospital, Cairo, Egypt
- 13Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | | | - Ronald E Warnick
- 15Gamma Knife Center, Jewish Hospital, Mayfield Clinic, Cincinnati, Ohio
| | - Yair M Gozal
- 15Gamma Knife Center, Jewish Hospital, Mayfield Clinic, Cincinnati, Ohio
| | - Megan Daly
- 16Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brendan McShane
- 16Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marcel Addis-Jackson
- 16Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gokul Karthikeyan
- 16Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sian Smith
- 16Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Piero Picozzi
- 17Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Milan, Italy
| | - Andrea Franzini
- 17Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Milan, Italy
| | - Tehila Kaisman-Elbaz
- 18Rose Ella Burkhart Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Huai-Che Yang
- 19Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 20National Yang Ming Chiao Tung University School of Medicine, Hsinchu, Taiwan
| | - Judith Hess
- 21Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Kelsey Templeton
- 21Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Xiaoran Zhang
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zhishuo Wei
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Gabriela Simonova
- 23Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- 23Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Selcuk Peker
- 24Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey; and
| | - Yavuz Samanci
- 24Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey; and
| | - Veronica Chiang
- 21Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Charles R Kersh
- 25Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Cheng-Chia Lee
- 19Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 20National Yang Ming Chiao Tung University School of Medicine, Hsinchu, Taiwan
| | - Daniel M Trifiletti
- 26Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida
| | - Ajay Niranjan
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - L Dade Lunsford
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 21Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
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Albalkhi I, Shafqat A, Bin-Alamer O, Mallela AN, Gersey ZC, Fernandes Cabral D, Sabbagh AJ, Hadjipanayis CG, González-Martínez JA, Friedlander RM, Abou-Al-Shaar H. Complications and visual outcomes following surgical resection of pediatric optic pathway/hypothalamic gliomas: a systematic review and meta-analysis. Childs Nerv Syst 2024:10.1007/s00381-024-06407-7. [PMID: 38649470 DOI: 10.1007/s00381-024-06407-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
Pediatric optic pathway/hypothalamic gliomas (OPHG) pose challenges in treatment due to their location and proximity to vital structures. Surgical resection plays a key role in the management of OPHG especially when the tumor exhibits mass effect and causes symptoms. However, data regarding outcomes and complications of surgical resection for OPHG remains heterogenous. The authors performed a systematic review on pediatric OPHG in four databases: PubMed, EMBASE, Cochrane Library, and Google Scholar. We included studies that reported on the visual outcomes and complications of OPHG resection. A meta-analysis was performed and reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 26 retrospective studies were included. Seven hundred ninety-seven pediatric patients with OPHG undergoing surgical resection were examined. A diagnosis of NF1 was confirmed in 9.7%. Gross total resection was achieved in 36.7%. Intraorbital optic pathway gliomas showed a significantly higher gross total resection rate compared to those located in the chiasmatic/hypothalamic region (75.8% vs. 9.6%). Postoperatively, visual acuity improved in 24.6%, remained unchanged in 68.2%, and worsened in 18.2%. Complications included hydrocephalus (35.4%), anterior pituitary dysfunction (19.6%), and transient diabetes insipidus (29%). Tumor progression post-resection occurred in 12.8%, through a mean follow-up of 53.5 months. Surgical resection remains an essential strategy for treating symptomatic and large pediatric OPHG and can result in favorable vision outcomes in most patients. Careful patient selection is critical. Patients should be monitored for hydrocephalus development postoperatively and followed up to assess for tumor progression and adjuvant treatment necessity.
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Affiliation(s)
- Ibrahem Albalkhi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zachary C Gersey
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Fernandes Cabral
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Abdulrahman J Sabbagh
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | | | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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5
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Rao A, Zhang X, Cillo AR, Sussman JH, Sandlesh P, Tarbay AC, Mallela AN, Cardello C, Krueger K, Xu J, Li A, Xu J, Patterson J, Akca E, Angione A, Jaman E, Kim WJ, Allen J, Venketeswaran A, Zinn PO, Parise R, Beumer J, Duensing A, Holland EC, Ferris R, Bagley SJ, Bruno TC, Vignali DAA, Agnihotri S, Amankulor NM. All-trans retinoic acid induces durable tumor immunity in IDH-mutant gliomas by rescuing transcriptional repression of the CRBP1-retinoic acid axis. bioRxiv 2024:2024.04.09.588752. [PMID: 38645178 PMCID: PMC11030316 DOI: 10.1101/2024.04.09.588752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Diffuse gliomas are epigenetically dysregulated, immunologically cold, and fatal tumors characterized by mutations in isocitrate dehydrogenase (IDH). Although IDH mutations yield a uniquely immunosuppressive tumor microenvironment, the regulatory mechanisms that drive the immune landscape of IDH mutant (IDHm) gliomas remain unknown. Here, we reveal that transcriptional repression of retinoic acid (RA) pathway signaling impairs both innate and adaptive immune surveillance in IDHm glioma through epigenetic silencing of retinol binding protein 1 (RBP1) and induces a profound anti-inflammatory landscape marked by loss of inflammatory cell states and infiltration of suppressive myeloid phenotypes. Restorative retinoic acid therapy in murine glioma models promotes clonal CD4 + T cell expansion and induces tumor regression in IDHm, but not IDH wildtype (IDHwt), gliomas. Our findings provide a mechanistic rationale for RA immunotherapy in IDHm glioma and is the basis for an ongoing investigator-initiated, single-center clinical trial investigating all-trans retinoic acid (ATRA) in recurrent IDHm human subjects.
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6
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Hect JL, Mallela AN, Pupi M, Anthony A, Fogg D, Ho J, Slingerland AL, Ikegaya N, Abou-Al-Shaar H, Aung T, Gonzalez-Martinez J. Safety of Concomitant Cortical and Thalamic Stereoencephalography Explorations in Patients With Drug-Resistant Epilepsies. Neurosurgery 2024:00006123-990000000-01098. [PMID: 38517164 DOI: 10.1227/neu.0000000000002919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/24/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intracranial electrophysiology of thalamic nuclei has demonstrated involvement of thalamic areas in the propagation of seizures in focal drug-resistant epilepsy. Recent studies have argued that thalamus stereoencephalography (sEEG) may aid in understanding the epileptogenic zone and treatment options. However, the study of thalamic sEEG-associated hemorrhage incidence has not been investigated in a cohort study design. In this article, we present the largest retrospective cohort study of sEEG patients and compare hemorrhage rates between those with and without thalamic sEEG monitoring. METHODS Retrospective chart review of clinical and epilepsy history, electrode implantation, rationale, and outcomes was performed for 76 patients (age 20-69 years) with drug-resistant epilepsy who underwent sEEG monitoring at our institution (2019-2022). A subset of 38% of patients (n = 30) underwent thalamic monitoring of the anterior thalamic nucleus (n = 14), pulvinar nucleus (n = 25), or both (n = 10). Planned perisylvian orthogonal sEEG trajectories were extended to 2- to 3-cm intraparenchymally access thalamic area(s).The decision to incorporate thalamic monitoring was made by the multidisciplinary epilepsy team. Statistical comparison of hemorrhage rate, type, and severity between patients with and without thalamic sEEG monitoring was made. RESULTS Our approach for thalamic monitoring was not associated with local intraparenchymal hemorrhage of thalamic areas or found along extended cortical trajectories, and symptomatic hemorrhage rates were greater for patients with thalamic coverage (10% vs 0%, P = .056), although this was not found to be significant. Importantly, patients with perisylvian electrode trajectories, with or without thalamic coverage, did not experience a higher incidence of hemorrhage (P = .34). CONCLUSION sEEG of the thalamus is a safe and valuable tool that can be used to interrogate the efficacy of thalamic neuromodulation for drug-resistant epilepsy. While patients with thalamic sEEG did have higher incidence of hemorrhage at any monitoring site, this finding was apparently not related to the method of perisylvian implantation and did not involve any trajectories targeting the thalamus.
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Affiliation(s)
- Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael Pupi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Austin Anthony
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David Fogg
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jonathan Ho
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anna L Slingerland
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Naoki Ikegaya
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Thandar Aung
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jorge Gonzalez-Martinez
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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7
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Sharma N, Head JR, Mallela AN, Shanahan RM, Canton SP, Abou-Al-Shaar H, Kass NM, Steuer F, Cheng L, Raver M, Andrews EG. Single institution series describing external ventricular drain (EVD) placement and short- and long-term complications related to placement accuracy. Surg Neurol Int 2024; 15:67. [PMID: 38468651 PMCID: PMC10927197 DOI: 10.25259/sni_894_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/05/2024] [Indexed: 03/13/2024] Open
Abstract
Background The placement of an external ventricular drain (EVD) for the treatment of acute hydrocephalus is one of the most common life-saving procedures that neurosurgeons perform worldwide. There are many well-known complications associated with EVD placement, including tract hemorrhages, intra-parenchymal and subdural hemorrhages, infection, and catheter misplacement. Given the variety of complications associated with EVD placement and the inconsistent findings on the relationship of accuracy to complications, the present study reviewed short- and long-term complications related to EVD placement at our institution. Methods A retrospective review was conducted for all consecutive patients who underwent bedside EVD placement for any indication between December 2020 and December 2021. Collected variables included demographic information, etiology of disease state, pre-and post-operative head computed tomography measurements, and post-procedural metrics (immediate and delayed complications). Results A total of 124 patients qualified for inclusion in our study. EVDs that were non-functioning/exchanged were not significantly related to age, accuracy, ventriculomegaly, sex, disposition, laterality, type of EVD used, intraventricular hemorrhage (IVH), etiology, or Kakarla Grade (KG) (all P > 0.17). The need for a second EVD was similarly not related to age, accuracy, ventriculomegaly, sex, disposition, location, laterality, type of EVD used, IVH, etiology, or KG (all P > 0.130). Patients who died, however, were significantly more likely to have a second contralateral EVD placed (18.2% vs. 4.9% P = 0.029). We also found that left-sided EVDs were significantly more likely to fail within seven days of placement (29.4% vs 13.3%, P = 0.037; relative risk (RR) 1.93, 95% confidence interval: 1.09-3.43), unrelated to age, sex, etiology, type of EVD, IVH, location of the procedure, or accuracy (all P > 0.07). This remained significant when using a binary logistic regression to control for ventriculomegaly, accuracy, mortality, age, sex, and etiology (P = 0.021, B = 3.43). Conclusion In our cohort, although a clear relationship between inaccuracy and complication rates was not found, our data did demonstrate that left-sided EVDs were more likely to fail within the immediate postoperative time point, and patients who died were more likely to have a second, contralateral EVD placed.
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Affiliation(s)
- Nikhil Sharma
- School of Medicine, University of Pittsburgh, Pennsylvania, United States
| | - Jeffery R. Head
- Department of Neurosurgery, University of Pittsburgh, Medical School, Pennsylvania, United States
| | - Arka N. Mallela
- Department of Neurosurgery, University of Pittsburgh, Medical School, Pennsylvania, United States
| | - Regan M. Shanahan
- School of Medicine, University of Pittsburgh, Pennsylvania, United States
| | - Stephen P. Canton
- Department of Orthopaedic Surgery Pittsburgh, Pennsylvania, United States
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, University of Pittsburgh, Medical School, Pennsylvania, United States
| | | | - Fritz Steuer
- School of Medicine, University of Pittsburgh, Pennsylvania, United States
| | - Lucille Cheng
- School of Medicine, University of Pittsburgh, Pennsylvania, United States
| | - Michael Raver
- School of Medicine, University of Pittsburgh, Pennsylvania, United States
| | - Edward G. Andrews
- Department of Neurosurgery, University of Pittsburgh, Medical School, Pennsylvania, United States
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8
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Bin-Alamer O, Abou-Al-Shaar H, Mallela AN, Kallos JA, Deng H, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Peker S, Samanci Y, Lee CC, Yang HC, Mathieu D, Tripathi M, Mantziaris G, Mullapudi A, Urgosik D, Liscak R, Bowden GN, Zaki P, Wegner RE, Shepard MJ, Sheehan JP, Niranjan A, Hadjipanayis CG, Lunsford LD. Intratumoral Hemorrhage in Vestibular Schwannomas After Stereotactic Radiosurgery: Multi-Institutional Study. Neurosurgery 2024; 94:289-296. [PMID: 37581440 DOI: 10.1227/neu.0000000000002627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/01/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intratumoral hemorrhage (ITH) in vestibular schwannoma (VS) after stereotactic radiosurgery (SRS) is exceedingly rare. The aim of this study was to define its incidence and describe its management and outcomes in this subset of patients. METHODS A retrospective multi-institutional study was conducted, screening 9565 patients with VS managed with SRS at 10 centers affiliated with the International Radiosurgery Research Foundation. RESULTS A total of 25 patients developed ITH (cumulative incidence of 0.26%) after SRS management, with a median ITH size of 1.2 cm 3 . Most of the patients had Koos grade II-IV VS, and the median age was 62 years. After ITH development, 21 patients were observed, 2 had urgent surgical intervention, and 2 were initially observed and had late resection because of delayed hemorrhagic expansion and/or clinical deterioration. The histopathology of the resected tumors showed typical, benign VS histology without sclerosis, along with chronic inflammatory cells and multiple fragments of hemorrhage. At the last follow-up, 17 patients improved and 8 remained clinically stable. CONCLUSION ITH after SRS for VS is extremely rare but has various clinical manifestations and severity. The management paradigm should be individualized based on patient-specific factors, rapidity of clinical and/or radiographic progression, ITH expansion, and overall patient condition.
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Affiliation(s)
- Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Justiss A Kallos
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Neurosurgery Department, Benha University, Qalubya , Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Neurosurgery Department, Ain Shams University, Cairo , Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Neurosurgery Department, Ain Shams University, Cairo , Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Clinical Oncology Department, Ain Shams University, Cairo , Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Neurosurgery Department, Ain Shams University, Cairo , Egypt
| | - Reem M Emad
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo , Egypt
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei , Taiwan
- School of Medicine, National Yang-Ming University, Taipei , Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei , Taiwan
- School of Medicine, National Yang-Ming University, Taipei , Taiwan
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke , Quebec , Canada
| | - Manjul Tripathi
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh , India
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Abhishek Mullapudi
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Dusan Urgosik
- Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Roman Liscak
- Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Greg N Bowden
- Department of Neurosurgery, University of Alberta, Edmonton , Canada
| | - Peter Zaki
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh , Pennsylvania , USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Allegheny Health Network, Pittsburgh , Pennsylvania , USA
| | - Matthew J Shepard
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh , Pennsylvania , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Constantinos G Hadjipanayis
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
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9
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Mallela AN, Plute TJ, Abou-Al-Shaar H, Fernandes Cabral DT, Hadjipanayis CG. Exoscope-based supracerebellar infratentorial approach for a pineal meningioma in the prone position. Neurosurg Focus Video 2024; 10:V15. [PMID: 38283816 PMCID: PMC10821642 DOI: 10.3171/2023.10.focvid23155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/20/2023] [Indexed: 01/30/2024]
Abstract
The supracerebellar infratentorial (SCIT) approach is a well-described corridor to lesions in the quadrigeminal cistern, pineal gland, and dorsal midbrain. It can be performed in the prone or sitting position. The sitting position offers the benefit of gravity retraction of the cerebellum but comes at the expense of nonergonomic hand positioning and the potential risk of air embolism. The 3D exoscope is an alternative to the operating microscope and permits the SCIT approach in the prone position with excellent visualization. This video demonstrates exoscope-based SCIT approach for resection of a pineal meningioma in the prone position. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23155.
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Affiliation(s)
- Arka N. Mallela
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Tritan J. Plute
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - David T. Fernandes Cabral
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Constantinos G. Hadjipanayis
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
- Hillman Cancer Center, Pittsburgh, Pennsylvania
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10
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Albalkhi I, Shafqat A, Bin-Alamer O, Abou Al-Shaar AR, Mallela AN, Fernández-de Thomas RJ, Zinn PO, Gerszten PC, Hadjipanayis CG, Abou-Al-Shaar H. Fluorescence-guided resection of intradural spinal tumors: a systematic review and meta-analysis. Neurosurg Rev 2023; 47:10. [PMID: 38085385 DOI: 10.1007/s10143-023-02230-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/13/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023]
Abstract
Intradural spinal tumors present significant challenges due to involvement of critical motor and sensory tracts. Achieving maximal resection while preserving functional tissue is therefore crucial. Fluorescence-guided surgery aims to improve resection accuracy and is well studied for brain tumors, but its efficacy has not been fully assessed for spinal tumors. This meta-analysis aims to delineate the efficacy of fluorescence guidance in intradural spinal tumor resection. The authors performed a systematic review in four databases. We included studies that have utilized fluorescence agents, 5-aminolevulinic acid (5-ALA) or sodium fluorescein, for the resection of intradural spinal tumors. A meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 12 studies involving 552 patients undergoing fluorescence-guided intradural spinal tumor resection were included. Meningiomas demonstrated a 98% fluorescence rate and were associated with a homogenous florescence pattern; however, astrocytomas had variable fluorescence rate with pooled proportion of 70%. There was no significant difference in gross total resection (GTR) rates between fluorescein and 5-ALA (94% vs 84%, p = .22). Pre-operative contrast enhancement was significantly associated with intraoperative fluorescence with fluorescein. Intramedullary tumors with positive intraoperative fluorescence were significantly associated with higher GTR rates (96% vs 73%, p = .03). Utilizing fluorescence guidance during intradural spinal tumor resection holds promise of improving intraoperative visualization for specific intradural spinal tumors. Meningiomas and ependymomas have the highest fluorescence rates especially with sodium fluorescein; on the other hand, astrocytomas have variable fluorescence rates with no superiority of either agent. Positive fluorescence of intramedullary tumors is associated with a higher degree of resection.
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Affiliation(s)
- Ibrahem Albalkhi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Pascal O Zinn
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter C Gerszten
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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11
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Head JR, Bin-Alamer O, Wei Z, Waite K, Agrawal N, Mallela AN, Faramand A, Gersey ZC, Niranjan A, Lunsford LD, Abou-Al-Shaar H. Vestibular Schwannoma Stereotactic Radiosurgery in Octogenarians: Case Series. Neurosurgery 2023; 93:1099-1105. [PMID: 37294094 DOI: 10.1227/neu.0000000000002552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/09/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The management of octogenarians with vestibular schwannomas (VS) has received little attention. However, with the increase in octogenarian population, more effort is needed to clarify the value of stereotactic radiosurgery (SRS) in this population. The aim of this study was to evaluate the safety and efficacy of SRS in this patient age group. METHODS A retrospective study of 62 patients aged 80 years or older who underwent single-session SRS for symptomatic VS during a 35-year interval was performed. The median patient age was 82 years, and 61.3% were male. SRS was performed as planned adjuvant management or for delayed progression after prior partial resection in 5 patients. RESULTS SRS resulted in a 5-year tumor control rate of 95.6% with a 4.8% risk of adverse radiation effects (ARE). Tumor control was unrelated to patient age, tumor volume, Koos grade, sex, SRS margin dose, or prior surgical management. Four patients underwent additional management including 1 patient with symptomatic progression requiring surgical resection, 2 patients with symptomatic hydrocephalus requiring cerebrospinal fluid diversion, and 1 patient whose tumor-related cyst required delayed cyst aspiration. Three patients developed ARE, including 1 patient with permanent facial weakness (House-Brackmann grade II), 1 who developed trigeminal neuropathy, and 1 who had worsening gait disorder. Six patients had serviceable hearing preservation before SRS, and 2 maintained serviceable hearing preservation after 4 years. A total of 44 (71%) patients died at an interval ranging from 6 to 244 months after SRS. CONCLUSION SRS resulted in tumor and symptom control in most octogenarian patients with VS.
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Affiliation(s)
- Jeffery R Head
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
- University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Kaitlin Waite
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Nishant Agrawal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
- University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Andrew Faramand
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Zachary C Gersey
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
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12
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Bin-Alamer O, Pikis S, Mantziaris G, Abdulbaki A, Mallela AN, Lu VM, Peker S, Samanci Y, Nabeel AM, Reda WA, Tawadros SR, El-Shehaby AMN, Abdelkarim K, Emad Eldin RM, Sheehan D, Sheehan K, Liscak R, Chytka T, Tripathi M, Madan R, Speckter H, Hernández W, Barnett GH, Hori YS, Dabhi N, Aldakhil S, Mathieu D, Kondziolka D, Bernstein K, Wei Z, Niranjan A, Kersh CR, Lunsford LD, Sheehan JP, Abou-Al-Shaar H. Adjuvant Stereotactic Radiosurgery With or Without Postresection Fractionated Radiation Therapy for the Management of Clival Chordomas in Adults: An International Multicenter Case Series. Neurosurgery 2023; 93:892-900. [PMID: 37052386 DOI: 10.1227/neu.0000000000002488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/13/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Clival chordomas are challenging because of their proximity to critical neurovascular structures. Stereotactic radiosurgery (SRS) has been proven effective with minimal adverse effects. OBJECTIVE To compare the outcomes of histologically confirmed primary clival chordomas in adults who underwent SRS alone (SRS group) vs SRS after fractionated radiotherapy (FRT+SRS group). METHODS We collected patient data from 10 institutions affiliated with the International Radiosurgery Research Foundation. We evaluated overall survival, tumor control, and freedom from additional treatment (FFAT). RESULTS Fifty-seven (77%) patients were included in the SRS group and 17 (23%) in the FRT+SRS group. The median radiological follow-up was 48 months (IQR, 24-85) in the SRS group and 36 months (IQR, 25-41) in the FRT+SRS group. During the follow-up, 8 SRS and 2 FRT+SRS patients died ( P = .80). The groups had comparable 10-year overall survival (SRS: 76% vs FRT+SRS: 80%; logrank test, P = .75) and tumor control rates (SRS: 34% vs FRT+SRS: 45%; logrank test, P = .29). The SRS group had a superior 10-year FFAT rate (40%) compared with FRT+SRS (23%; logrank test, P = .02). This finding persisted in the multivariate analysis of the Cox proportional hazards illustrating a 2.40-fold increase in the relative risk of requiring additional treatment among the FRT+SRS group ( P = .04). CONCLUSION Adjuvant FRT with subsequent boost SRS did not provide superior overall survival or tumor control compared with patients who underwent adjuvant SRS alone. Further studies are required to refine management guidelines among adults with clival chordomas.
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Affiliation(s)
- Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Stylianos Pikis
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Arif Abdulbaki
- Department of Neurosurgery, Hannover Medical School, Hannover , Germany
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Victor M Lu
- Department of Neurological Surgery, University of Miami School of Medicine, Miami , Florida , USA
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Benha University, Benha , Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Reem M Emad Eldin
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo , Egypt
| | - Darrah Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Kimball Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Roman Liscak
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Tomas Chytka
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Manjul Tripathi
- Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh , India
| | - Renu Madan
- Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh , India
| | - Herwin Speckter
- Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo , Dominican Republic
| | - Wenceslao Hernández
- Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo , Dominican Republic
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland , Ohio , USA
| | - Yusuke S Hori
- Department of Neurosurgery, Cleveland Clinic, Cleveland , Ohio , USA
| | - Nisha Dabhi
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Salman Aldakhil
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke , Quebec , Canada
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke , Quebec , Canada
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone, New York , New York , USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, New York University Langone, New York , New York , USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Charles R Kersh
- Department of Radiation Oncology, University of Virginia, Charlottesville , Virginia , USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
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13
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Bin-Alamer O, Abou-Al-Shaar H, Mallela AN, Niranjan A, Sheehan JP, Lunsford LD. In Reply: Stereotactic Radiosurgery for Vestibular Schwannoma in Neurofibromatosis Type 2: An International Multicenter Case Series of Response and Malignant Transformation Risk. Neurosurgery 2023; 93:e100-e101. [PMID: 37498090 DOI: 10.1227/neu.0000000000002614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 07/28/2023] Open
Affiliation(s)
- Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
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14
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Plute T, Abou-Al-Shaar H, McDowell MM, Mallela AN, Snyderman CH, Gardner PA. Endoscopic Endonasal Resection of a Recurrent Prepontine Neurenteric Cyst: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e226. [PMID: 37366620 DOI: 10.1227/ons.0000000000000799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/24/2023] [Indexed: 06/28/2023] Open
Affiliation(s)
- Tritan Plute
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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15
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Fogg D, Gersey ZC, Pease M, Mallela AN, Andrews E, Plute T, Pearce TM, Njoku-Austin C, Anthony A, Amankulor NM, Zinn P. Outcomes and Treatment Algorithm in Glioblastoma Patients 80 Years and Older. World Neurosurg 2023; 178:e540-e548. [PMID: 37516146 DOI: 10.1016/j.wneu.2023.07.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/23/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVE The current standard of care for patients with glioblastoma (GBM) is maximal safe resection followed by adjuvant radiation therapy with concurrent temozolomide chemotherapy. Previous studies that identified this treatment regimen focused on younger patients with GBM. The proportion of patients with GBM over the age of 80 years is increasing. We investigate whether elderly patients benefit from the current standard of care with additional maximal safe resection. METHODS Clinical, operative, radiographic, demographic, genetic, and outcomes data were retrospectively collected for patients treated for histologically confirmed World Health Organization grade 4 GBM at University of Pittsburgh Medical Center from 2009 to 2020. Only patients 80 years and older were included (n = 123). Statistically significant values were set at P < 0.05. RESULTS A univariate Cox proportional hazards analysis of GBM patients aged >80 years identified the use of temozolomide, radiation, Karnofsky Performance Status (KPS) > 70, and methylguanine DNA methyltransferase methylation with increased overall survival (OS). Further multivariate Cox proportional hazards model analysis showed that the variables identified in the univariate analysis passed multicollinearity testing, and that use of temozolomide, KPS >70, and gross total resection were shown to significantly impact survival. Survival analysis showed that patients with biopsy alone had a shorter median OS compared with patients who received resection, temozolomide, and radiation (P < 0.0001, median OS 1.6 vs. 7.5 months). Additionally, patients who underwent biopsy and then received temozolomide and radiation had a shorter median OS when compared with patients who received resection, temozolomide, and radiation (P = 0.0047, median OS 3.6 vs. 7.5 months). CONCLUSIONS For elderly patients with KPS >70, GTR followed by radiation and temozolomide is associated with maximum OS.
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Affiliation(s)
- David Fogg
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Zachary C Gersey
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Matthew Pease
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Edward Andrews
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tritan Plute
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Thomas M Pearce
- Division of Neuropathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Austin Anthony
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Nduka M Amankulor
- Department of Neurosurgery, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pascal Zinn
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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16
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Patel A, Abdelsalam A, Shariff RK, Mallela AN, Andrews EG, Tonetti DA, Lunsford LD, Abou-Al-Shaar H. Bibliometric analysis of the top 100 cited articles on stereotactic radiosurgery of intracranial meningiomas. Br J Neurosurg 2023; 37:1088-1093. [PMID: 35142245 DOI: 10.1080/02688697.2022.2034745] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/23/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Sterotactic radiosurgery is becoming an integral modality in the management of intracranial meningiomas, both as the primary treatment or as adjuvant therapy. This study analyzes the scholarly impact of the top 100 cited articles on the stereotactic radiosurgical management of intracranial meningiomas. METHODS A ranked list of the 100 most-cited articles was generated using the Scopus database by searching the keywords 'intracranial meningioma' and 'stereotactic radiosurgery'. All articles were then evaluated on multiple criteria regarding both the publication of the articles (year of publication, journal, country of origin, and authors) as well as their methods and foci (type of study, location of studied meningiomas, and type of radiosurgical modality). Quantitaitve and qualitative analyses were then performed from the collected data. RESULTS The most frequently cited articles on stereotactic radiosurgical management of intracranial meningiomas were published between 1990 and 2016. The average citation-per-year across all papers in the list was 6.1. The most studied anatomic area of intracranial meningiomas was the skull base, with the cavernous sinus being the most well-studied specific site. The most utilized stereotactic radiosurgical modality was Gamma Knife radiosurgery. The country with the highest number of publications was the United States. Twenty-six percent of the articles were published in the journal Neurosurgery; Lunsford, Kondziolka, Flickinger, Sheehan, and Pollock were respectively the most frequent listed authors among this list. The most active academic institute publishing on this topic was the University of Pittsburgh Medical Center. CONCLUSION Stereotactic radiosurgery is an integral modality in the management of intracranial meningiomas. This bibliometric analysis sheds the light on the ways in which intracranial meningiomas have been studied in the past two decades in order to identify trends among neurosurgeons and radiation oncologists and to reveal areas of rising and declining focus.
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Affiliation(s)
- Aneek Patel
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Ahmed Abdelsalam
- Department of Neurology, Saint Louis University Hospital, St. Louis, MO, USA
| | - Rimsha K Shariff
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Edward G Andrews
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel A Tonetti
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Albalkhi I, Shafqat A, Bin-Alamer O, Mallela AN, Kuminkoski C, Labib MA, Lang MJ, Lawton MT, Morcos JJ, Couldwell WT, Abou-Al-Shaar H. Long-term functional outcomes and complications of microsurgical resection of brainstem cavernous malformations: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:252. [PMID: 37726558 DOI: 10.1007/s10143-023-02152-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/03/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
Brainstem cavernous malformations (CMs) encompass up to 20% of all intracranial CMs and are considered more aggressive than cerebral CMs because of their high annual bleeding rates. Microsurgical resection remains the primary treatment modality for CMs, but long-term functional outcomes and complications are heterogenous in the literature. The authors performed a systematic review on brainstem CMs in 4 databases: PubMed, EMBASE, Cochrane library, and Google Scholar. We included studies that reported on the long-term functional outcomes and complications of brainstem CMs microsurgical resection. A meta-analysis was performed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search yielded 4781 results, of which 19 studies met our inclusion criteria. Microsurgery was performed on 940 patients (mean age 35 years, 46.9% females). Most of the brainstem CMs were located in the pons (n = 475). The pooled proportions of improved, stable, and worsened functional outcomes after microsurgical resection of brainstem CMs were 56.7% (95% CI 48.4-64.6), 28.6% (95% CI 22.4-35.7), and 12.6% (95% CI 9.6-16.2), respectively. CMs located in the medulla were significantly (p = 0.003) associated with a higher proportion of improved outcome compared with those in the pons and midbrain. Complete resection was achieved in 93.3% (95% CI 89.8-95.7). The immediate postoperative complication rate was 37.2% (95% CI 29.3-45.9), with new-onset cranial nerve deficit being the most common complication. The permanent morbidity rate was 17.3% (95% CI 10.5-27.1), with a low mortality rate of 1% from the compiled study population during a mean follow-up of 58 months. Our analysis indicates that microsurgical resection of brainstem CMs can result in favorable long-term functional outcomes with transient complications in the majority of patients. Complete microsurgical resection of the CM is associated with a lower incidence of CM hemorrhage and the morbidity related to it.
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Affiliation(s)
- Ibrahem Albalkhi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Chloe Kuminkoski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mohamed A Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jacques J Morcos
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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18
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Yoh N, Abou-Al-Shaar H, Bethamcharla R, Beiriger J, Mallela AN, Connolly ES, Sekula RF. Minimally invasive surgical evacuation for spontaneous cerebellar hemorrhage: a case series and systematic review. Neurosurg Rev 2023; 46:208. [PMID: 37612544 DOI: 10.1007/s10143-023-02118-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/06/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
Spontaneous cerebellar hemorrhage (scICH) is a subset of intracerebral hemorrhage accounting for 5-10% of all cases. Despite potential advantages, minimally invasive surgical evacuation of scICH may be an underutilized strategy when compared to unilateral or bilateral large suboccipital craniectomy or craniotomy, with or without duraplasty. We performed a retrospective single-center cohort study and a systematic literature review. Radiographic and clinical data were recorded and analyzed. Five consecutive patients with minimally invasive surgical evacuation of scICH were identified. Average hematoma size was 16.4 ± 3.0 cm3. Mean Glasgow coma score (GCS) prior to surgery was 11.6 ± 3.0 with improvement to 14.6 ± 0.4 postoperatively. Mean hematoma evacuation was 92.6 ± 0.6% as confirmed by postoperative computed tomography (CT) imaging. All patients achieved a modified Rankin Scale (mRS) score of 0 or 1 with an average follow-up time of 31 ± 22 months. Mean length of hospital stay was 8.8 ± 3.0 days. No patients experienced significant complications or required reoperation. Systematic review revealed similar results for minimally invasive evacuation of scICH when reporting disaggregated outcomes. A review of recent studies utilizing large unilateral or bilateral suboccipital craniectomy or craniotomy, with or without duraplasty, revealed higher morbidity and mortality rates than minimally invasive surgical evacuation of scICH. Minimally invasive evacuation of scICH is safe and effective. Near complete evacuation of hematoma can be achieved with lower morbidity and mortality than large suboccipital craniectomy or craniotomy. A multi-center, prospective, and rigorous trial comparing the two strategies for evacuation of scICH is warranted.
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Affiliation(s)
- Nina Yoh
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, USA
| | - Raviteja Bethamcharla
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA
| | - Justin Beiriger
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA
- Columbia University Vagelos College of Physicians and Surgeons, 710 West 168th Street, 4th Floor, New York, NY, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA.
- Columbia University Vagelos College of Physicians and Surgeons, 710 West 168th Street, 4th Floor, New York, NY, USA.
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19
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Pease M, Elmer J, Shahabadi AZ, Mallela AN, Ruiz-Rodriguez JF, Sexton D, Barot N, Gonzalez-Martinez JA, Shutter L, Okonkwo DO, Castellano JF. Predicting posttraumatic epilepsy using admission electroencephalography after severe traumatic brain injury. Epilepsia 2023; 64:1842-1852. [PMID: 37073101 DOI: 10.1111/epi.17622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVE Posttraumatic epilepsy (PTE) develops in as many as one third of severe traumatic brain injury (TBI) patients, often years after injury. Analysis of early electroencephalographic (EEG) features, by both standardized visual interpretation (viEEG) and quantitative EEG (qEEG) analysis, may aid early identification of patients at high risk for PTE. METHODS We performed a case-control study using a prospective database of severe TBI patients treated at a single center from 2011 to 2018. We identified patients who survived 2 years postinjury and matched patients with PTE to those without using age and admission Glasgow Coma Scale score. A neuropsychologist recorded outcomes at 1 year using the Expanded Glasgow Outcomes Scale (GOSE). All patients underwent continuous EEG for 3-5 days. A board-certified epileptologist, blinded to outcomes, described viEEG features using standardized descriptions. We extracted 14 qEEG features from an early 5-min epoch, described them using qualitative statistics, then developed two multivariable models to predict long-term risk of PTE (random forest and logistic regression). RESULTS We identified 27 patients with and 35 without PTE. GOSE scores were similar at 1 year (p = .93). The median time to onset of PTE was 7.2 months posttrauma (interquartile range = 2.2-22.2 months). None of the viEEG features was different between the groups. On qEEG, the PTE cohort had higher spectral power in the delta frequencies, more power variance in the delta and theta frequencies, and higher peak envelope (all p < .01). Using random forest, combining qEEG and clinical features produced an area under the curve of .76. Using logistic regression, increases in the delta:theta power ratio (odds ratio [OR] = 1.3, p < .01) and peak envelope (OR = 1.1, p < .01) predicted risk for PTE. SIGNIFICANCE In a cohort of severe TBI patients, acute phase EEG features may predict PTE. Predictive models, as applied to this study, may help identify patients at high risk for PTE, assist early clinical management, and guide patient selection for clinical trials.
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Affiliation(s)
- Matthew Pease
- Department of Neurological Surgery, University of Pittsburgh Medical Center Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Jonathan Elmer
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ameneh Zare Shahabadi
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Juan F Ruiz-Rodriguez
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Daniel Sexton
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Niravkumar Barot
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jorge A Gonzalez-Martinez
- Department of Neurological Surgery, University of Pittsburgh Medical Center Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Lori Shutter
- Department of Neurological Surgery, University of Pittsburgh Medical Center Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center Healthcare System, Pittsburgh, Pennsylvania, USA
| | - James F Castellano
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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20
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Mallela AN, Deng H, Gholipour A, Warfield SK, Goldschmidt E. Heterogeneous growth of the insula shapes the human brain. Proc Natl Acad Sci U S A 2023; 120:e2220200120. [PMID: 37279278 PMCID: PMC10268209 DOI: 10.1073/pnas.2220200120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 04/13/2023] [Indexed: 06/08/2023] Open
Abstract
The human cerebrum consists of a precise and stereotyped arrangement of lobes, primary gyri, and connectivity that underlies human cognition [P. Rakic, Nat. Rev. Neurosci. 10, 724-735 (2009)]. The development of this arrangement is less clear. Current models explain individual primary gyrification but largely do not account for the global configuration of the cerebral lobes [T. Tallinen, J. Y. Chung, J. S. Biggins, L. Mahadevan, Proc. Natl. Acad. Sci. U.S.A. 111, 12667-12672 (2014) and D. C. Van Essen, Nature 385, 313-318 (1997)]. The insula, buried in the depths of the Sylvian fissure, is unique in terms of gyral anatomy and size. Here, we quantitatively show that the insula has unique morphology and location in the cerebrum and that these key differences emerge during fetal development. Finally, we identify quantitative differences in developmental migration patterns to the insula that may underlie these differences. We calculated morphologic data in the insula and other lobes in adults (N = 107) and in an in utero fetal brain atlas (N = 81 healthy fetuses). In utero, the insula grows an order of magnitude slower than the other lobes and demonstrates shallower sulci, less curvature, and less surface complexity both in adults and progressively throughout fetal development. Spherical projection analysis demonstrates that the lenticular nuclei obstruct 60 to 70% of radial pathways from the ventricular zone (VZ) to the insula, forcing a curved migration to the insula in contrast to a direct radial pathway. Using fetal diffusion tractography, we identify radial glial fascicles that originate from the VZ and curve around the lenticular nuclei to form the insula. These results confirm existing models of radial migration to the cortex and illustrate findings that suggest differential insular and cerebral development, laying the groundwork to understand cerebral malformations and insular function and pathologies.
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Affiliation(s)
- Arka N. Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA15213
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA15213
| | - Ali Gholipour
- Department of Radiology, Harvard Medical School, Boston, MA02115
- Department of Radiology, Boston Children’s Hospital, Boston, MA02115
| | - Simon K. Warfield
- Department of Radiology, Harvard Medical School, Boston, MA02115
- Department of Radiology, Boston Children’s Hospital, Boston, MA02115
| | - Ezequiel Goldschmidt
- Department of Radiology, Harvard Medical School, Boston, MA02115
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA94143
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21
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Sharma N, Mallela AN, Abou-Al-Shaar H, Aung T, Gonzalez-Martinez J. Trans-Interhemispheric Stereoelectroencephalography Depth Electrode Placement for Mesial Frontal Lobe Explorations in Medically Refractory Epilepsy: A Technical Note and Case Series. Oper Neurosurg (Hagerstown) 2023; 24:582-589. [PMID: 36786750 DOI: 10.1227/ons.0000000000000631] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 11/18/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Stereoelectroencephalography (SEEG) is an established and safe methodology for extra-operative invasive monitoring in patients with medical refractory epilepsy. SEEG has several advantages such as the ability to record deep cortical structures, mapping the epileptogenic zone in a three-dimensional manner, and analyze bihemispheric regions without the need for bilateral craniotomies. In patients with bilateral hemispheric hypotheses, especially the mesial surface of frontal lobes, bilateral lead placement is compulsory to further define and localize the epileptogenic zone. In this particular cohort of patients, bilateral monitoring may be accomplished from a single entry point using trans-interhemispheric placement of the electrodes. The use of trans-interhemispheric monitoring offers several advantages including sparing the need for additional leads. OBJECTIVE To test the hypothesis that, given the lack of the falx as a limiting structure in the ventral and mesial frontal lobe regions, trans-interhemispheric SEEG placement is feasible and a potential benefit for the SEEG method. METHODS We report on 6 patients who underwent bilateral monitoring using trans-interhemispheric SEEG lead placement and discuss the operative technique. RESULTS Six patients underwent trans-interhemispheric monitoring, with a median of 3 leads per patient (19 total). Trajectory error was minimal (<0.3 mm), and operating room time was comparable with that in previous reports. All leads were placed without adverse events, mislocalization, electrode hemorrhages, or any other complications. All patients had successful localization of the epileptogenic zone. CONCLUSION Trans-interhemispheric SEEG to monitor the mesial wall of frontal lobe regions is technically feasible. No adverse events were observed, suggesting a favorable safety profile.
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Affiliation(s)
- Nikhil Sharma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Thandar Aung
- Department of Neurology and Epilepsy Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jorge Gonzalez-Martinez
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurology and Epilepsy Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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22
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Plute T, Agarwal P, Patel A, Mallela AN, Lunsford LD, Abou-Al-Shaar H. Idiopathic De Novo Arteriovenous Malformation: A Rare Acquired Intracranial Lesion. Asian J Neurosurg 2023; 18:400-403. [PMID: 37397049 PMCID: PMC10313434 DOI: 10.1055/s-0043-1769893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
The de novo development of cerebral arteriovenous malformations (AVMs) in adults is an exceedingly rare event that has prompted the theory that a "second hit" is required to induce AVM formation. The authors document development of an occipital AVM in an adult a decade and a half after a brain magnetic resonance imaging (MRI) disclosed no abnormality. A 31-year-old male with a family history of AVMs and a 14-year history of migraines with visual auras and seizures presented to our service. Because of the onset of a first seizure and migraine headaches at age 17, the patient underwent high-resolution MRI that showed no intracranial lesion. After 14 years of progressively worsening symptoms, he underwent a repeat MRI that demonstrated a new de novo Spetzler-Martin grade 3 left occipital AVM. The patient received anticonvulsants and underwent Gamma Knife radiosurgery for his AVM. This case suggests that patients with seizures or persistent migraine headaches should have periodic repeat neuroimaging to exclude the development of a vascular cause despite an initial negative MRI.
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Affiliation(s)
- Tritan Plute
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Prateek Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Aneek Patel
- Department of Neurological Surgery, New York University Langone Health, New York, New York, United States
| | - Arka N. Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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23
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Pease M, Mallela AN, Elmer J, Okonkwo DO, Shutter L, Barot N, Gonzalez-Martinez J, Castellano JF. Association of Posttraumatic Epilepsy With Long-term Functional Outcomes in Individuals With Severe Traumatic Brain Injury. Neurology 2023; 100:e1967-e1975. [PMID: 36948595 PMCID: PMC10186228 DOI: 10.1212/wnl.0000000000207183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 01/27/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Nearly one-third of patients with severe traumatic brain injury (TBI) develop posttraumatic epilepsy (PTE). The relationship between PTE and long-term outcomes is unknown. We tested whether, after controlling for injury severity and age, PTE is associated with worse functional outcomes after severe TBI. METHODS We performed a retrospective analysis of a prospective database of patients with severe TBI treated from 2002 through 2018 at a single level 1 trauma center. Glasgow Outcome Scale (GOS) was collected at 3, 6, 12, and 24 months postinjury. We used repeated-measures logistic regression predicting GOS, dichotomized as favorable (GOS 4-5) and unfavorable (GOS 1-3), and a separate logistic model predicting mortality at 2 years. We used predictors as defined by the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) base model (i.e., age, pupil reactivity, and GCS motor score), PTE status, and time. RESULTS Of 392 patients who survived to discharge, 98 (25%) developed PTE. The proportion of patients with favorable outcomes at 3 months did not differ between those with and without PTE (23% [95% Confidence Interval [CI]: 15%-34%] vs 32% [95% CI: 27%-39%]; p = 0.11) but was significantly lower at 6 (33% [95% CI: 23%-44%] vs 46%; [95% CI: 39%-52%] p = 0.03), 12 (41% [95% CI: 30%-52%] vs 54% [95% CI: 47%-61%]; p = 0.03), and 24 months (40% [95% CI: 47%-61%] vs 55% [95% CI: 47%-63%]; p = 0.04). This was driven by higher rates of GOS 2 (vegetative) and 3 (severe disability) outcomes in the PTE group. By 2 years, the incidence of GOS 2 or 3 was double in the PTE group (46% [95% CI: 34%-59%]) compared with that in the non-PTE group (21% [95% CI: 16%-28%]; p < 0.001), while mortality was similar (14% [95% CI: 7%-25%] vs 23% [95% CI: 17%-30%]; p = 0.28). In multivariate analysis, patients with PTE had lower odds of favorable outcome (odds radio [OR] 0.1; 95% CI: 0.1-0.4; p < 0.001), but not mortality (OR 0.9; 95% CI: 0.1-1.9; p = 0.46). DISCUSSION Posttraumatic epilepsy is associated with impaired recovery from severe TBI and poor functional outcomes. Early screening and treatment of PTE may improve patient outcomes.
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Affiliation(s)
- Matthew Pease
- From the Departments of Neurosurgery (M.P., A.N., D.O.O., J.G-M.), Neurology (J.E., L.S., N.B., J.F.C.), Critical Care (J.E., L.S.), and Emergency Medicine (J.E.), University of Pittsburgh Medical Center, PA.
| | - Arka N Mallela
- From the Departments of Neurosurgery (M.P., A.N., D.O.O., J.G-M.), Neurology (J.E., L.S., N.B., J.F.C.), Critical Care (J.E., L.S.), and Emergency Medicine (J.E.), University of Pittsburgh Medical Center, PA
| | - Jonathan Elmer
- From the Departments of Neurosurgery (M.P., A.N., D.O.O., J.G-M.), Neurology (J.E., L.S., N.B., J.F.C.), Critical Care (J.E., L.S.), and Emergency Medicine (J.E.), University of Pittsburgh Medical Center, PA
| | - David O Okonkwo
- From the Departments of Neurosurgery (M.P., A.N., D.O.O., J.G-M.), Neurology (J.E., L.S., N.B., J.F.C.), Critical Care (J.E., L.S.), and Emergency Medicine (J.E.), University of Pittsburgh Medical Center, PA
| | - Lori Shutter
- From the Departments of Neurosurgery (M.P., A.N., D.O.O., J.G-M.), Neurology (J.E., L.S., N.B., J.F.C.), Critical Care (J.E., L.S.), and Emergency Medicine (J.E.), University of Pittsburgh Medical Center, PA
| | - Niravkumar Barot
- From the Departments of Neurosurgery (M.P., A.N., D.O.O., J.G-M.), Neurology (J.E., L.S., N.B., J.F.C.), Critical Care (J.E., L.S.), and Emergency Medicine (J.E.), University of Pittsburgh Medical Center, PA
| | - Jorge Gonzalez-Martinez
- From the Departments of Neurosurgery (M.P., A.N., D.O.O., J.G-M.), Neurology (J.E., L.S., N.B., J.F.C.), Critical Care (J.E., L.S.), and Emergency Medicine (J.E.), University of Pittsburgh Medical Center, PA
| | - James F Castellano
- From the Departments of Neurosurgery (M.P., A.N., D.O.O., J.G-M.), Neurology (J.E., L.S., N.B., J.F.C.), Critical Care (J.E., L.S.), and Emergency Medicine (J.E.), University of Pittsburgh Medical Center, PA
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24
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Bin-Alamer O, Qedair J, Palmisciano P, Mallela AN, Nayar GM, Lu VM, Labib MA, Lang MJ, Gross BA, Langer DJ, Couldwell WT, Friedlander RM, Abou-Al-Shaar H. Dolichoectatic vertebrobasilar aneurysms: a systematic review and meta-analysis of management strategies and outcomes. Neurosurg Focus 2023; 54:E9. [PMID: 37127027 DOI: 10.3171/2023.2.focus22650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/13/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE The aim of this study was to describe the efficacy, clinical outcomes, and complications of open cerebrovascular surgery, endovascular surgery, and conservative management of dolichoectatic vertebrobasilar aneurysms (DVBAs). METHODS Relevant articles were retrieved from PubMed, Scopus, Web of Science, and Cochrane databases according to PRISMA guidelines. A meta-analysis was conducted for clinical presentation, treatment protocols, and clinical outcomes-good (improved or stable clinical status) or poor (deteriorated clinical status or death)-and mortality rates. RESULTS The 9 identified articles described 41 cases (27.5%) of open cerebrovascular surgery, 61 endovascular procedures (40.9%), and 47 cases (31.5%) of conservative management for DVBAs. The total cohort had a good outcome rate of 51.9% (95% CI 28.3%-74.6%), a poor outcome rate of 45.5% (95% CI 23.0%-70.1%), and a mortality rate of 22.3% (95% CI 11.8%-38.0%). The treatment groups had comparable good clinical outcome rates (open cerebrovascular surgery group: 24.7% [95% CI 2.9%-78.2%]; endovascular surgery group: 69.0% [95% CI 28.7%-92.5%]; conservative management group: 57.7% [95% CI 13.0%-92.5%]; p = 0.19) and poor outcome rates (open vascular surgery group: 75.3% [95% CI 21.8%-97.1%]; endovascular surgery group: 27.2% [95% CI 5.6%-0.70.2%]; conservative management group: 39.9% [95% CI 9.1%-81.6%]; p = 0.15). The treatment groups also had comparable mortality rates (open vascular surgery group: 39.5% [95% CI 11.4%-76.8%]; endovascular surgery group: 15.8% [95% CI 4.4%-43.0%]; conservative management group: 19.2% [95% CI 6.8%-43.5%]; p = 0.23). CONCLUSIONS The current study of DVBAs illustrated poor outcomes and high mortality rates regardless of the treatment modality. The subgroup analysis showed heterogeneity among the subgroups and advice for personalized management.
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Affiliation(s)
- Othman Bin-Alamer
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jumanah Qedair
- 2College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Paolo Palmisciano
- 3Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Arka N Mallela
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gautam M Nayar
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Victor M Lu
- 4Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida
| | - Mohamed A Labib
- 5Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael J Lang
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bradley A Gross
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David J Langer
- 6Department of Neurosurgery, Lenox Hill Hospital, New York, New York; and
| | - William T Couldwell
- 7Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Robert M Friedlander
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hussam Abou-Al-Shaar
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Bin-Alamer O, Faramand A, Alarifi NA, Wei Z, Mallela AN, Lu VM, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AM, Emad RM, Peker S, Samanci Y, Lee CC, Yang HC, Delabar V, Mathieu D, Tripathi M, Kearns KN, Bunevicius A, Sheehan JP, Chytka T, Liscak R, Moreno NM, Álvarez RM, Grills IS, Parzen JS, Cifarelli CP, Rehman AA, Speckter H, Niranjan A, Lunsford LD, Abou-Al-Shaar H. Stereotactic Radiosurgery for Vestibular Schwannoma in Neurofibromatosis Type 2: An International Multicenter Case Series of Response and Malignant Transformation Risk. Neurosurgery 2023; 92:934-944. [PMID: 36861994 PMCID: PMC10079356 DOI: 10.1227/neu.0000000000002436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/09/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Vestibular schwannomas (VSs) related to neurofibromatosis type 2 (NF2) are challenging tumors. The increasing use of stereotactic radiosurgery (SRS) necessitates further investigations of its role and safety. OBJECTIVE To evaluate tumor control, freedom from additional treatment (FFAT), serviceable hearing preservation, and radiation-related risks of patients with NF2 after SRS for VS. METHODS We performed a retrospective study of 267 patients with NF2 (328 VSs) who underwent single-session SRS at 12 centers participating in the International Radiosurgery Research Foundation. The median patient age was 31 years (IQR, 21-45 years), and 52% were male. RESULTS A total of 328 tumors underwent SRS during a median follow-up time of 59 months (IQR, 23-112 months). At 10 and 15 years, the tumor control rates were 77% (95% CI: 69%-84%) and 52% (95% CI: 40%-64%), respectively, and the FFAT rate were 85% (95% CI: 79%-90%) and 75% (95% CI: 65%-86%), respectively. At 5 and 10 years, the serviceable hearing preservation rates were 64% (95% CI: 55%-75%) and 35% (95% CI: 25%-54%), respectively. In the multivariate analysis, age (hazards ratio: 1.03 [95% CI: 1.01-1.05]; P = .02) and bilateral VSs (hazards ratio: 4.56 [95% CI: 1.05-19.78]; P = .04) were predictors for serviceable hearing loss. Neither radiation-induced tumors nor malignant transformation were encountered in this cohort. CONCLUSION Although the absolute volumetric tumor progression rate was 48% at 15 years, the rate of FFAT related to VS was 75% at 15 years after SRS. None of the patients with NF2-related VS developed a new radiation-related neoplasm or malignant transformation after SRS.
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Affiliation(s)
- Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew Faramand
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Norah A. Alarifi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurosurgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N. Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Victor M. Lu
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Ahmed M. Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department, Benha University, Qalubya, Egypt
| | - Wael A. Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Sameh R. Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Amr M.N. El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Reem M. Emad
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Cheng-chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Violaine Delabar
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Manjul Tripathi
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kathryn Nicole Kearns
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Adomas Bunevicius
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Tomas Chytka
- Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Inga S. Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, USA
| | - Jacob S. Parzen
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, USA
| | | | - Azeem A. Rehman
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
| | - Herwin Speckter
- Department of Radiology, Centro Gamma Knife Dominicano and Radiology Department, Cedimat, Santo Domingo, Dominican Republic
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Parikh P, Abdallah HM, Patel A, Shariff RK, Nowicki KW, Mallela AN, Tonetti DA, Sekula RF, Lunsford LD, Abou-Al-Shaar H. Bibliometric Analysis of the Top 100 Cited Articles on Stereotactic Radiosurgery for Trigeminal Neuralgia. Asian J Neurosurg 2023; 18:101-107. [PMID: 37056872 PMCID: PMC10089752 DOI: 10.1055/s-0043-1761240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Background Stereotactic radiosurgical rhizolysis of the trigeminal nerve is an established modality increasingly employed to alleviate the symptoms of refractory trigeminal neuralgia. This study analyzes the academic impact of the top 100 cited articles on the radiosurgical management of trigeminal neuralgia.
Methods The Scopus database was searched for articles containing “radiosurgery” and one or more of “trigeminal neuralgia,” “trigeminus neuralgia,” and “tic douloureux.” The top 100 articles written in English were arranged in descending order by citation count. Documents were evaluated for authors, publication year, journal and impact factor, total citations, nationality, study type, radiosurgical modality, and the affiliated institution. Quantitative and qualitative analyses were performed on the data.
Results The most cited articles were published between 1971 and 2019. The average citation per year was 4.3. The most targeted anatomic area was the “root entry zone” or proximal portion of the cisternal segment of the trigeminal nerve. The most utilized modality was Gamma Knife radiosurgery. The country with the highest number of publications was the United States. Thirty-six percent of the articles were published in the Journal of Neurosurgery. Lunsford, Kondziolka, Flickinger, and Régis, respectively, were the most frequently listed co-authors. The most prolific institute was the University of Pittsburgh Medical Center.
Conclusion Stereotactic radiosurgery is an important modality in the management of medically or surgically refractory trigeminal neuralgia. This analysis assesses its contributions over the past five decades to identify trends in treatment practices for neurosurgeons and to highlight areas where further study is needed.
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27
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Tang LW, Mallela AN, Deng H, Richardson TE, Hervey-Jumper SL, McBrayer SK, Abdullah KG. Preclinical modeling of lower-grade gliomas. Front Oncol 2023; 13:1139383. [PMID: 37051530 PMCID: PMC10083350 DOI: 10.3389/fonc.2023.1139383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/16/2023] [Indexed: 03/28/2023] Open
Abstract
Models for human gliomas prove critical not only to advancing our understanding of glioma biology but also to facilitate the development of therapeutic modalities. Specifically, creating lower-grade glioma (LGG) models has been challenging, contributing to few investigations and the minimal progress in standard treatment over the past decade. In order to reliably predict and validate the efficacies of novel treatments, however, LGG models need to adhere to specific standards that recapitulate tumor genetic aberrations and micro-environment. This underscores the need to revisit existing models of LGG and explore prospective models that may bridge the gap between preclinical insights and clinical translation. This review first outlines a set of criteria aimed to address the current challenges hindering model development. We then evaluate the strengths and weaknesses of existing preclinical models of LGG with respect to these established standards. To conclude, the review discusses potential future directions for integrating existing models to maximize the exploration of disease mechanisms and therapeutics development.
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Affiliation(s)
- Lilly W. Tang
- Physician Scientist Training Program, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
- Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Arka N. Mallela
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Timothy E. Richardson
- Department of Pathology, Cell and Molecular Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Shawn L. Hervey-Jumper
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Samuel K. McBrayer
- Children's Medical Center Research Institute, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Kalil G. Abdullah
- Physician Scientist Training Program, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
- Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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28
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Muthiah N, Mallela AN, Vodovotz L, Sharma N, Akwayena E, Pan E, Welch W, Ibrahim GM, Abel TJ. Development of a clinical model to predict vagus nerve stimulation response in pediatric patients with drug-resistant epilepsy. J Neurosurg Pediatr 2023; 31:476-483. [PMID: 36805960 DOI: 10.3171/2023.1.peds22312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 01/13/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE Epilepsy impacts 470,000 children in the United States. For patients with drug-resistant epilepsy (DRE) and unresectable seizure foci, vagus nerve stimulation (VNS) is a treatment option. Predicting response to VNS has been historically challenging. The objective of this study was to create a clinical VNS prediction tool for use in an outpatient setting. METHODS The authors performed an 11-year retrospective cohort analysis with 1-year follow-up. Patients < 21 years of age with DRE who underwent VNS (n = 365) were included. Logistic regressions were performed to assess clinical factors associated with VNS response (≥ 50% seizure frequency reduction after 1 year); 70% and 30% of the sample were used to train and validate the multivariable model, respectively. A prediction score was subsequently developed. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were calculated. RESULTS Variables associated with VNS response were < 4-year epilepsy duration before VNS (p = 0.008) and focal motor seizures (p = 0.037). The variables included in the clinical prediction score were epilepsy duration before VNS, age at seizure onset, number of pre-VNS antiseizure medications, if VNS was the patient's first therapeutic epilepsy surgery, and predominant seizure semiology. The final AUCs were 0.7013 for the "fitted" sample and 0.6159 for the "validation" sample. CONCLUSIONS The authors developed a clinical model to predict VNS response in a large sample of pediatric patients treated with VNS. Despite the large sample size, clinical variables alone were not able to accurately predict VNS response. This score may be useful after further validation, although its predictive ability underscores the need for more robust biomarkers to predict treatment response.
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Affiliation(s)
| | - Arka N Mallela
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Lena Vodovotz
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Nikhil Sharma
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Emefa Akwayena
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Evelyn Pan
- 1Department of Neurological Surgery, University of Pittsburgh
| | - William Welch
- 2Department of Pediatrics, Division of Child Neurology, University of Pittsburgh, Pennsylvania
| | - George M Ibrahim
- 3Department of Surgery, Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada; and
| | - Taylor J Abel
- 1Department of Neurological Surgery, University of Pittsburgh.,4Department of Bioengineering, University of Pittsburgh, Pennsylvania
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29
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Plute T, Patel A, Mallela AN, Sefcik RK, Hamilton DK, Lunsford LD, Friedlander RM, Abou-Al-Shaar H. United States Neurosurgery Department Program Directors: A Cross-Sectional Evaluation of Current and Future Trends and Attributes. World Neurosurg 2023; 170:e550-e557. [PMID: 36402302 DOI: 10.1016/j.wneu.2022.11.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND While United States (U.S.) neurosurgery residency programs have been subject to many studies, none have focused solely on the program directors (PDs). We aim to analyze the demographic, educational, and academic attributes of this cohort to understand current and future trends of PDs. METHODS One hundred sixteen neurosurgeons listed as PDs at U.S. accredited neurosurgical residency training programs as of August 2022 were assessed. Descriptive data including age upon acceptance of role, gender, and h-index were collected from publicly available sources. RESULTS Most PDs matriculated to their positions before the age of 45 years, were male, and had been hired internally. Approximately 25% of PDs had earned an additional degree. Departments with higher aggregate h-indexes were more likely to hire PDs with higher average publications per year (P < 0.001) and have a higher h-index (P < 0.001). PD subspecialty influenced h-index (P < 0.05) and total average publications per year (P < 0.05) with neuro-oncology subspecialists having higher averages in both. More recently hired PDs had a higher average number of publications per year (P < 0.05) and were more likely to hold an additional degree (odds ratio 1.14, P < 0.05). Female PDs were hired at a younger age (P < 0.05). CONCLUSIONS Neurosurgery PDs typically rise to their position after 10 years of practice and more recent PD hires are more likely to have additional degrees and more publications. As academic neurosurgery becomes more competitive, increased academic productivity and acquisition of additional degrees will become increasingly necessary.
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Affiliation(s)
- Tritan Plute
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Aneek Patel
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Roberta K Sefcik
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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30
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Bin-Alamer O, Fogg D, Wei Z, Duehr J, Mallela AN, Niranjan A, Lunsford LD, Abou-Al-Shaar H. Intratumoral hemorrhage in vestibular schwannomas after stereotactic radiosurgery. J Neurosurg 2023; 138:413-419. [PMID: 35901754 DOI: 10.3171/2022.5.jns22935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Vestibular schwannomas (VSs) are benign tumors of the cerebellopontine angle that are typically managed with stereotactic radiosurgery (SRS). Intratumoral hemorrhage (ITH) of VSs is a rare occurrence that results in worsening vestibular and new cranial nerve deficits. Few reports have described the management and outcomes of this entity after SRS. To further delineate the incidence and impact of this event, the authors performed a retrospective review of their VS SRS patients at a single center. METHODS Between 1987 and 2022, 2058 patients with VSs underwent Gamma Knife radiosurgery (GKRS) at the University of Pittsburgh Medical Center. The authors performed a review of the prospectively maintained VS database at their center to identify patients with ITH. The presentation, management, and clinical and imaging outcomes of the patients are reported. RESULTS A total of 1902 VS patients had sufficient clinical and imaging follow-up data. Five Koos grade III (n = 1) and IV (n = 4) VS patients developed ITH after GKRS, resulting in a cumulative incidence rate of 0.26%. The age at presentation ranged from 62 to 79 years, and 3 patients were male. The time from VS diagnosis to GKRS ranged from 1 to 13 months, and the time from GKRS to ITH ranged from 2 to 130 months. Three patients had bleeding risk factors. One patient required urgent surgical intervention due to the ITH volume, while the other 4 patients were initially observed. Three patients remained stable and required no delayed intervention; 1 patient required delayed resection because of symptom progression and hemorrhagic expansion. Histopathological analysis revealed multiple fragments of S-100-positive cells, hemorrhage, and hemosiderin-laden macrophages. At last follow-up, 4 patients had clinically improved and 1 patient remained stable. CONCLUSIONS ITH after VS radiosurgery is a rare phenomenon with a cumulative incidence rate of 0.26% in this series. Patient-tailored management in the form of observation or resection is based on patient presentation, acuity, and ITH size.
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Affiliation(s)
- Othman Bin-Alamer
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, and
| | - David Fogg
- 2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Zhishuo Wei
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, and.,2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - James Duehr
- 2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Arka N Mallela
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, and
| | - Ajay Niranjan
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, and
| | - L Dade Lunsford
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, and
| | - Hussam Abou-Al-Shaar
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, and
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Abou-Al-Shaar H, Patel KP, Mallela AN, Sekula RF. Lateral supraorbital approach for resection of large and giant olfactory groove meningiomas: a single center experience. Br J Neurosurg 2023; 37:90-96. [PMID: 36053047 DOI: 10.1080/02688697.2022.2117273] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND The lateral supraorbital approach (LSO) provides an optimal access corridor for various skull bases lesions, including olfactory groove meningiomas (OGMs). The aim of this study is to describe the authors' experience with the management of large and giant OGMs utilizing the LSO approach and describe the technical nuances of the procedure. METHODS A retrospective review of seven patients with large and giant OGMs managed with the LSO approach between 2013 and 2019 was performed. Radiographic and clinical data were recorded and analyzed. RESULTS Seven patients with large and giant OGMs underwent surgical resection via the LSO approach. Six patients were female, with a median age of 56 years. Patients commonly presented with altered mentation, anosmia, and headaches. The average tumor volume was 120.6 ± 64.7 cm3 with five cases of vascular encasement. Simpson grade II resection was achieved in four patients while Simpson grade IV resection was achieved in three patients. The median length of stay was 2.0 days. The median preoperative Karnofsky Performance Scale (KPS) score was 70, improving to 100 at last postoperative follow-up visit. Two complications were encountered in the form of postoperative cerebrospinal fluid leak in one patient and a transient diplopia in another patient. Tumor recurrence/progression was identified in two patients during a median follow-up time of 65.5 months. Both cases have been managed with adjuvant radiosurgery. CONCLUSION The LSO approach is a safe and effective minimally invasive transcranial corridor for the management of OGMs that should be part of the armamentarium of skull base neurosurgeons.
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Affiliation(s)
- Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin P Patel
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA.,Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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32
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Bin-Alamer O, Alnefaie N, Qedair J, Chaudhary A, Hallak H, Abdulbaki A, Mallela AN, Palmisciano P, Gersey ZC, Legarreta AD, Labib MA, Zada G, Sheehan JP, Couldwell WT, Lunsford LD, Abou-Al-Shaar H. Single session versus multisession stereotactic radiosurgery for the management of intracranial meningiomas: a systematic review and meta-analysis. J Neurooncol 2023; 161:215-224. [PMID: 35976546 DOI: 10.1007/s11060-022-04112-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/03/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE To compare the efficacy, outcomes, and complications of single session (SS-SRS) and multisession (MS-SRS) stereotactic radiosurgery in the treatment of intracranial meningiomas. METHODS Relevant articles were retrieved from PubMed, Scopus, Web of Science, and Cochrane. A systematic review and meta-analysis of treatment protocols and outcomes were conducted. After the selection process, 20 articles describing 1483 cases were included. RESULTS A total of 1303 patients who underwent SS-SRS and 180 patients who underwent MS-SRS for the management of their intracranial meningioma were reported in the included studies. SS-SRS and MS-SRS had comparable one-year (SS-SRS: 98% vs. MS-SRS: 100%, p > 0.99) and five-year (SS-SRS: 94% vs. MS-SRS: 93%, p = 0.71) tumor control rates. The groups also had comparable tumor volume reduction/tumor regression rates (SS-SRS: 44% vs. MS-SRS: 25%, p = 0.25), tumor volume stability rates (SS-SRS: 51% vs. MS-SRS: 75%, p = 0.12), and tumor progression rates (SS-SRS: 4% vs. MS-SRS: 4%, p = 0.89). SS-SRS and MS-SRS yielded similar complication rates (10.4% vs. 11.4%, p = 0.68) and comparable functional improvement rates (MS-SRS: 44% vs. SS-SRS: 36%, p = 0.57). However, MS-SRS was used for significantly larger tumor volumes (MS-SRS: 23.8 cm3 vs. SS-SRS: 6.1 cm3, p = 0.02). CONCLUSION SS-SRS and MS-SRS resulted in comparable tumor control, tumor volumetric change, and functional outcomes despite significant biases in selecting patients for SS- or MS-SRS.
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Affiliation(s)
- Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nada Alnefaie
- Department of Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Jumanah Qedair
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Adhiraj Chaudhary
- Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Hana Hallak
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Arif Abdulbaki
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Zachary C Gersey
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew D Legarreta
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mohamed A Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Sharma N, Mallela AN, Shi DD, Tang LW, Abou-Al-Shaar H, Gersey ZC, Zhang X, McBrayer SK, Abdullah KG. Isocitrate dehydrogenase mutations in gliomas: A review of current understanding and trials. Neurooncol Adv 2023; 5:vdad053. [PMID: 37287696 PMCID: PMC10243983 DOI: 10.1093/noajnl/vdad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
Isocitrate dehydrogenase (IDH) is a key enzyme in normal metabolism and homeostasis. However, mutant forms of IDH are also defining features of a subset of diffuse gliomas. In this review, we highlight current techniques targeting IDH-mutated gliomas and summarize current and completed clinical trials exploring these strategies. We discuss clinical data from peptide vaccines, mutant IDH (mIDH) inhibitors, and PARP inhibitors. Peptide vaccines have the unique advantage of targeting the specific epitope of a patient's tumor, inducing a highly tumor-specific CD4+ T-cell response. mIDH-inhibitors, on the other hand, specifically target mutant IDH proteins in cancer cell metabolism and thus help halt gliomagenesis. We also explore PARP inhibitors and their role in treating diffuse gliomas, which exploit IDH-mutant diffuse gliomas by allowing the persistence of unrepaired DNA complexes. We summarize various completed and current trials targeting IDH1 and IDH2 mutations in diffuse gliomas. Therapies targeting mutant IDH have significant promise in treating progressive or recurrent IDH-mutant gliomas and may significantly change treatment paradigms in the next decade.
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Affiliation(s)
- Nikhil Sharma
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Diana D Shi
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Lilly W Tang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Xiaoran Zhang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Samuel K McBrayer
- Children’s Medical Center Research Institute, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kalil G Abdullah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Abou-Al-Shaar H, Patel A, Mallela AN, Bin-Alamer O, Niranjan A, Peker S, Samanci Y, Liscak R, May J, Kumar JS, Sheehan JP, Lunsford LD. Chronic Encapsulated Expanding Hematomas After Stereotactic Radiosurgery for Intracranial Arteriovenous Malformations: An International Multicenter Case Series. Neurosurgery 2023; 92:195-204. [PMID: 36519863 DOI: 10.1227/neu.0000000000002175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/04/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) offers a minimally invasive treatment modality for appropriately selected intracranial arteriovenous malformations (AVMs). Recent reports have described the development of rare, delayed chronic encapsulated expanding hematomas (CEEHs) at the site of an angiographically confirmed obliterated AVM. OBJECTIVE To elucidate the incidence, characteristics, and management of CEEH in patients with AVM after SRS. METHODS The records of all patients who underwent SRS for an intracranial AVM at 4 institutions participating in the International Radiosurgery Research Foundation between 1987 and 2021 were retrospectively reviewed. Data regarding characteristics of the AVM, SRS treatment parameters, CEEH presentation, management, and outcomes were collected and analyzed. RESULTS Among 5430 patients, 15 developed a CEEH at a crude incidence of 0.28%. Nine patients were female, and the mean age was 43 ± 14.6 years. Nine patients underwent surgical evacuation, while 6 were managed conservatively. The median CEEH development latency was 106 months after SRS. The patients were followed for a median of 32 months, and 9 patients improved clinically, while 6 patients remained stable. No intraoperative complications were reported after CEEH resection, although 1 patient recovered from postoperative meningitis requiring intravenous antibiotics. CONCLUSION CEEH is a rare, late complication of AVM SRS with an incidence of 0.28% and a median latency of 106 months. In the presence of a delayed and symptomatic expanding hematoma in the bed of an angiographically obliterated AVM, surgical resection resulted in clinical improvement in most patients. Conservative management is possible in asymptomatic patients with stable, small-sized hematomas in deeply seated locations.
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Affiliation(s)
- Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aneek Patel
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Roman Liscak
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir May
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jeyan Sathia Kumar
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Wei Z, Yavan S, Deng H, Mallela AN, Gersey ZC, Shariff RK, Fazeli PK, Niranjan A, Lunsford LD, Abou-Al-Shaar H. The role of stereotactic radiosurgery in the multidisciplinary management of pituitary metastases. Pituitary 2022; 25:948-958. [PMID: 36203008 DOI: 10.1007/s11102-022-01279-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 10/10/2022]
Abstract
PURPOSE This study evaluates the role and outcomes of Gamma Knife radiosurgery (GKRS) in the management of pituitary metastases. METHODS The records of brain metastases patients who underwent GKRS at the University of Pittsburgh Medical Center during the 10-year interval of 2010-2020 were systematically reviewed. Outcome measures included patient survival, tumor control rate, pituitary hormonal outcomes, visual outcomes, adverse radiation effects (AREs), and need for adjuvant therapy. RESULTS Eighteen patients with pituitary metastases (eight male; median age of 65.5 years) had sufficient clinical follow-up for analysis. The most common primary cancers were non-small cell lung cancer (n = 6) and breast cancer (n = 4). Patients presented with headache (n = 9) and visual difficulties (n = 6). One patient underwent resection before GKRS. The median tumor volume was 0.78 cc (range 0.04-6.42 cc). The median overall survival after GKRS was 6.5 months (range 0.5-58 months). The overall survival after GKRS at 3-, 6-, and 12-months were 72.2%, 50.0% and 38.9%, respectively. The tumor control rate was 94.4%. One patient had further progression that required additional GKRS. None of the patients developed AREs after GKRS. CONCLUSION GKRS is an effective treatment modality for the multidisciplinary management of patients with pituitary metastases. This minimally-invasive strategy is associated with optimal tumor control rate and low risk to adjacent optic nerves or neurovascular structures.
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Affiliation(s)
- Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-200, Pittsburgh, PA, 15213, USA
| | - Sila Yavan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-200, Pittsburgh, PA, 15213, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-200, Pittsburgh, PA, 15213, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-200, Pittsburgh, PA, 15213, USA
| | - Zachary C Gersey
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-200, Pittsburgh, PA, 15213, USA
| | - Rimsha K Shariff
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Endocrinology and Metabolism, Neuroendocrinology Unit, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pouneh K Fazeli
- Division of Endocrinology and Metabolism, Neuroendocrinology Unit, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-200, Pittsburgh, PA, 15213, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-200, Pittsburgh, PA, 15213, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-200, Pittsburgh, PA, 15213, USA.
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Mallela AN, Abou-Al-Shaar H, González-Martínez J. Letter to the Editor. SEEG and subdural grids: differences that go beyond morbidity. J Neurosurg 2022; 138:885-886. [PMID: 36401541 DOI: 10.3171/2022.8.jns221901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Mallela AN, Beiriger J, Gersey ZC, Shariff RK, Gonzalez SM, Agarwal N, González-Martínez JA, Abou-Al-Shaar H. Targeting the Future: Developing a Training Curriculum for Robotic Assisted Neurosurgery. World Neurosurg 2022; 167:e770-e777. [PMID: 36030012 DOI: 10.1016/j.wneu.2022.08.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Technological advances have significantly fostered the use of robotics in neurosurgery. Due to their novelty, there is a need to develop training methods within neurosurgical residency programs that provide trainees the skills to utilize these systems in their future practices safely and effectively. METHODS We describe a detailed curriculum for trainees with significant responsibilities in the operating room, as well as hands-on and theoretical didactics. The curriculum for robot-assisted stereotactic electroencephalography (SEEG) and deep brain stimulation (DBS) electrode implantation technique and assessment tool has been designed based on Accreditation Council for Graduate Medical Education's (ACGME's) milestone requirement for surgical treatment of epilepsy and movement disorders. Residents were surveyed to assess their use of robotics in their surgical training. RESULTS Since 2019, more than 100 patients have undergone robot-assisted SEEG and DBS depth electrode implantations at our institution. Residents and fellows were involved in all aspects of surgical planning and execution and were encouraged to take an active role during procedures. Didactic sessions led by experienced faculty are emphasized as important learning tools prior to hands-on experience in the operating room. The results of the survey show that residents receive more training intraoperatively as compared to training sessions, yet trainees would benefit from more instruction on informative cadaveric simulation sessions. CONCLUSIONS Our curriculum was developed to become a structured tool for assessment of robotic education in neurosurgical training. This curriculum based on ACGME milestone requirements serve as a template for resident and fellow education in robotics in neurosurgery.
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Affiliation(s)
- Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Justin Beiriger
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zachary C Gersey
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rimsha K Shariff
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sophia M Gonzalez
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jorge A González-Martínez
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Bin-Alamer O, Mallela AN, Palmisciano P, Gersey ZC, Elarjani T, Labib MA, Zenonos GA, Dehdashti AR, Sheehan JP, Couldwell WT, Lunsford LD, Abou-Al-Shaar H. Adjuvant stereotactic radiosurgery with or without postoperative fractionated radiation therapy in adults with skull base chordomas: a systematic review. Neurosurg Focus 2022; 53:E5. [DOI: 10.3171/2022.8.focus22239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE
The objective of this retrospective study was to compare the survival of patients with biopsy-proven skull base chordoma who had undergone stereotactic radiosurgery (SRS) with versus without prior fractionated radiation therapy (RT).
METHODS
Relevant articles from database inception to September 2021 were retrieved from the PubMed, Scopus, Web of Science, and Cochrane databases for a systematic review of treatment protocols. Studies were included if they 1) involved adult patients (age ≥ 18 years) with histologically and radiologically confirmed chordomas located within the clival skull base region and treated with SRS; 2) reported data on clinical features, SRS protocols, and outcomes; and 3) were written in the English language. Studies were excluded if they 1) were literature reviews, case reports, technical notes, abstracts, or autopsy reports; 2) did not clearly differentiate the data of patients with chordomas from the data of patients with different tumors or the data of patients with chordomas in locations other than the skull base; or 3) lacked histological confirmation or treatment and outcome data. Extracted data included the following: study author and publication year, patient age and sex, symptoms, cranial nerve involvement, invaded structures, lesion size, treatment modality, surgical details, histopathological type, RT modality, SRS parameters, complications, postradiosurgery outcomes, complications, and survival outcomes.
RESULTS
After the selection process, 15 articles describing 130 patients met the study eligibility criteria, including 94 patients who had undergone postresection SRS (NoRT group) and 36 who had undergone postresection fractionated RT and subsequent SRS (RT group). The NoRT and RT groups were comparable in age (51.3 vs 47.4 years, respectively), sex (57.1% vs 58.3% male), tumor volume (9.5 vs 11.2 cm3), SRS treatment parameters (maximum dose: 35.4 vs 42.2 Gy, marginal dose: 19.6 vs 20.6 Gy, treatment isodose line: 60.2% vs 65.2%), and SRS adverse effects (10.9% vs 17.6%). For the entire cohort, the 3-, 5-, and 10-year progression-free survival (PFS) rates were 23%, 9%, and 3%, respectively, and the overall survival (OS) rates were 94%, 82%, and 76%, respectively. In the NoRT group, SRS was adjuvant treatment after resection in 38 patients (40.4%), salvage treatment for recurrent tumor treated with resection alone in 10 (10.6%), and not specified in 46 (48.9%). In the RT group, SRS was boost treatment in 9 patients (25.0%), salvage treatment after recurrence in 22 (61.1%), and not specified in 5 (13.9%). There was no difference between the two groups in terms of median PFS (24.0 months [Q1 34.0, Q3 15.0] vs 23.8 months [34.0, 18.0], respectively; p = 0.8) or median OS (293.0 months [not reached, 137.4] vs not reached [not reached, 48.0], respectively; p = 0.36). The adverse radiation effect rates were comparable between the groups (10.9% vs 17.6%, respectively; p = 0.4).
CONCLUSIONS
The role of SRS in the management of skull base chordomas is still evolving. This systematic literature review of biopsy-proven chordoma revealed that tumor control and survival rates for SRS alone after chordoma surgery were not inferior to those encountered after SRS plus fractionated RT.
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Affiliation(s)
- Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arka N. Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Zachary C. Gersey
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Turki Elarjani
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Mohamed A. Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Georgios A. Zenonos
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amir R. Dehdashti
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Jason P. Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Gonzalez-Martinez JA, Abou-Al-Shaar H, Mallela AN, McDowell MM, Henry L, Fernandes Cabral DT, Sweat J, Urban A, Fong J, Barot N, Castellano JF, Rajasekaran V, Bagic A, Snyderman CH, Gardner PA. The endoscopic anterior transmaxillary temporal pole approach for mesial temporal lobe epilepsies: a feasibility study. J Neurosurg 2022; 138:992-1001. [PMID: 36087323 DOI: 10.3171/2022.7.jns221062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In mesial temporal lobe epilepsy (MTLE), the ideal surgical approach to achieve seizure freedom and minimize morbidity is an unsolved question. Selective approaches to mesial temporal structures often result in suboptimal seizure outcomes. The authors report the results of a pilot study intended to evaluate the clinical feasibility of using an endoscopic anterior transmaxillary (eATM) approach for minimally invasive management of MTLEs. METHODS The study is a prospectively collected case series of four consecutive patients who underwent the eATM approach for the treatment of MTLE and were followed for a minimum of 12 months. All participants underwent an epilepsy workup and surgical care at a tertiary referral comprehensive epilepsy center and had medically refractory epilepsy. The noninvasive evaluations and intracranial recordings of these patients confirmed the presence of anatomically restricted epileptogenic zones located in the mesial temporal structures. Data on seizure freedom at 1 year, neuropsychological outcomes, diffusion tractography, and adverse events were collected and analyzed. RESULTS By applying the eATM technique and approaching the far anterior temporal lobe regions, mesial-basal resections of the temporal polar areas and mesial temporal structures were successfully achieved in all patients (2 with left-sided approaches, 2 with right-sided approaches). No neurological complications or neuropsychological declines were observed. All 4 patients achieved Engel class Ia outcome up to the end of the follow-up period (19, 15, 14, and 12 months). One patient developed hypoesthesia in the left V2 distribution but there were no other adverse events. The low degree of white matter injury from the eATM approach was analyzed using high-definition fiber tractography in 1 patient as a putative mechanism for preserving neuropsychological function. CONCLUSIONS The described series demonstrates the feasibility and potential safety profile of a novel approach for medically refractory MTLE. The study affirms the feasibility of performing efficacious mesial temporal lobe resections through an eATM approach.
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Affiliation(s)
- Jorge A Gonzalez-Martinez
- 1Epilepsy Center, University of Pittsburgh Medical Center, Pittsburgh.,Departments of3Neurological Surgery
| | | | | | | | | | | | | | - Alexandra Urban
- 1Epilepsy Center, University of Pittsburgh Medical Center, Pittsburgh.,4Neurology, and
| | - Joanna Fong
- 1Epilepsy Center, University of Pittsburgh Medical Center, Pittsburgh.,4Neurology, and
| | - Niravkumar Barot
- 1Epilepsy Center, University of Pittsburgh Medical Center, Pittsburgh.,4Neurology, and
| | - James F Castellano
- 1Epilepsy Center, University of Pittsburgh Medical Center, Pittsburgh.,4Neurology, and
| | | | - Anto Bagic
- 1Epilepsy Center, University of Pittsburgh Medical Center, Pittsburgh.,4Neurology, and
| | - Carl H Snyderman
- 2Skull Base Center, University of Pittsburgh Medical Center, Pittsburgh; and.,5Otorhinolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- 2Skull Base Center, University of Pittsburgh Medical Center, Pittsburgh; and.,Departments of3Neurological Surgery
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Abou-Al-Shaar H, Mallela AN, Patel A, Shariff RK, Shin SS, Choi PA, Faraji AH, Fazeli PK, Costacou T, Wang EW, Fernandez-Miranda JC, Snyderman CH, Gardner PA, Zenonos GA. The role of endoscopic endonasal surgery in the management of prolactinomas based on their invasiveness into the cavernous sinus. Pituitary 2022; 25:508-519. [PMID: 35467273 DOI: 10.1007/s11102-022-01221-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To review our institutional experience with the surgical management of prolactinomas through the endoscopic endonasal approach with specific focus on cavernous sinus invasion. METHODS Clinical and radiographic data were collected retrospectively from the electronic medical record of 78 consecutive patients with prolactinomas undergoing endoscopic endonasal resection from 2002 to 2019. Immediate and late post-operative remission were defined as prolactin < 20 ng/mL within 14 days and 1-year of surgery without adjuvant therapy, respectively. Cavernous sinus invasion was quantified by Knosp score. RESULTS A total of 78 patients with prolactinoma, 59% being male, underwent surgical resection with a mean age of 37 ± 13 years. Indications for surgery were medication resistance in 38 patients (48.7%), medication intolerance in 11 (14.1%), and patient preference in 29 (37.2%). Patients with Knosp 0-2 achieved higher immediate remission rates (83.8%) compared to patients with Knosp 3 (58.8%) and Knosp 4 (41.7%) patients (p = 0.003). Long-term remission rates were 48.7% and increased to 71.8% when combined with adjuvant treatments. Knosp 4 prolactinomas had significantly higher tumor volumes, higher preoperative prolactin levels, higher recurrence rates, higher rates of adjuvant therapy utilization, and were more likely to have failed dopamine agonist therapy compared to other tumor grades (p < 0.05). We encountered 18 complications in our series, and no cerebrospinal fluid leaks. CONCLUSION The endoscopic endonasal approach is a safe and effective modality that can be employed in properly selected patients with invasive prolactinomas. It is associated with improved control and remission rates despite cavernous sinus invasion, though at a lower rate than without invasion.
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Affiliation(s)
- Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Aneek Patel
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rimsha K Shariff
- Neuroendocrinology Unit, Division of Endocrinology and Metabolism, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Samuel S Shin
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Phillip A Choi
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Amir H Faraji
- Department of Neurosurgery, Houston Methodist, Houston, TX, USA
| | - Pouneh K Fazeli
- Neuroendocrinology Unit, Division of Endocrinology and Metabolism, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tina Costacou
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Georgios A Zenonos
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Abou-Al-Shaar H, Mallela AN, Algattas HN, Rogers R, Friedlander RM. Ventriculoperitoneal Shunt Failure Due to Distal Peritoneal Catheter Kinking. Am J Case Rep 2022; 23:e935077. [PMID: 35379769 PMCID: PMC8994830 DOI: 10.12659/ajcr.935077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Hydrocephalus is a common condition associated with high morbidity and mortality rates. Despite advancements in shunt systems and valve designs, complications associated with ventriculoperitoneal (VP) shunts are steadily recognized and reported in the literature. Here, we present an unusual case of VP shunt failure due to catheter kinking at the site of the slits in the distal peritoneal catheter. CASE REPORT A 30-year-old woman with type I Chiari malformation, prior suboccipital craniectomy, and shunted hydrocephalus with prior revisions presented with 2 months of progressive, low-pressure headaches. Shunt series X-rays demonstrated kinking of the distal peritoneal catheter. A computed tomography (CT) scan showed interval enlargement of her ventricles concerning for shunt failure, which prompted return to the operating room. During shunt revision, her valve was nonfunctioning with loss of resistance and her distal catheter was kinked at the most proximal peritoneal slit. Postoperative shunt series X-rays demonstrated an intact shunt system without kinking or discontinuity and a CT of her head showed interval decease in the caliber of her ventricles. CONCLUSIONS Distal peritoneal catheter kinking at the site of slits is an unusual complication of VP shunts and should be considered. Surgeons should add this possibility to the differential diagnosis of shunt malfunction when an imaging irregularity is identified in the peritoneal catheter.
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Bin Alamer O, Palmisciano P, Mallela AN, Labib MA, Gardner PA, Couldwell WT, Lunsford LD, Abou-Al-Shaar H. Stereotactic radiosurgery in the management of petroclival meningiomas: a systematic review and meta-analysis of treatment outcomes of primary and adjuvant radiosurgery. J Neurooncol 2022; 157:207-219. [PMID: 35301638 DOI: 10.1007/s11060-021-03934-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 12/21/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To summarize the clinical features and outcomes of petroclival meningioma patients treated with stereotactic radiosurgery (SRS) as either a primary or an adjuvant modality. METHODS Relevant articles were retrieved from PubMed, Scopus, Web of Science, and Cochrane. A systematic review and meta-analysis of treatment outcomes comparing primary and adjuvant SRS was conducted. RESULTS Seven articles comprising 722 cases were included. The mean tumor marginal dose was 13.5 Gy. After SRS, symptoms improved in 28.7%, remained unchanged in 61.3%, and worsened in 10.0% of the cohort. Tumor control was achieved in 94.8% of patients. The mean tumor volume change was -6.4 cm3. The 5-year and 10-year progression-free survival (PFS) rates were 91-100% and 69.6-89.9%, respectively. Overall, 61.9% of patients underwent primary radiosurgery, and 38.1% had adjuvant radiosurgery. Patients who had primary SRS reported higher rates of tumor control (94.3% vs. 88.2%) and fewer SRS-related complications (3.7% vs. 10.3%) than those who received adjuvant SRS (not accounting for microsurgical complications). The functional status of patients who had primary SRS was more likely to improve or remain unchanged, with an effect size of 1.12 (95% CI 1.1-1.25; I2 = 0). Neither group displayed superiority in worsening functional outcomes or tumor control rate. CONCLUSION SRS of petroclival meningiomas was associated with excellent long-term PFS and local tumor control rates. Primary SRS was highly effective for patients with smaller volume lesions without clinically symptomatic mass effect. In patients who warrant initial resection, adjuvant radiosurgery remains an important modality to prevent regrowth while maintaining postresection function.
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Affiliation(s)
- Othman Bin Alamer
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Paolo Palmisciano
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA, 15213, USA
| | - Mohamed A Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA, 15213, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA, 15213, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA, 15213, USA.
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Hallak H, Abou-Al-Shaar H, Mallela AN, McDowell MM, Jabbour N, Padia R, Greene S, Pollack IF. The Eyebrow Approach for the Management of Pediatric Frontal Epidural Abscesses Secondary to Diffuse Sinusitis. Pediatr Neurosurg 2022; 57:213-221. [PMID: 35398851 DOI: 10.1159/000524537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/01/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Minimally invasive approaches to the anterior cranial fossa have evolved over the past few decades. The management of frontal epidural abscesses (EDAs) secondary to diffuse sinusitis in the pediatric population using minimally invasive techniques is scarcely reported in the literature. Herein, we report the utilization of a minimally invasive eyebrow approach for multidisciplinary concurrent evacuation of frontal EDA secondary to diffuse sinusitis and trephination of the frontal sinus in three pediatric patients. CASE REPORTS Three pediatric patients presented to the emergency room with severe headaches, visual changes, somnolence, and significant facial and periorbital swelling. Imaging revealed diffuse sinusitis with focal frontal epidural extension. In all cases, progressive clinical deterioration along with the radiographic findings mandated urgent surgical intervention. The eyebrow approach allowed for concomitant evacuation of the frontal EDA and trephination of the frontal sinus followed by functional endoscopic sinus surgery in the same setting. All patients tolerated the procedure well with complete resolution of their symptoms at the completion of antibiotic therapy and complete resolution of the EDA. CONCLUSION The eyebrow approach is a minimally invasive technique that should be considered as part of the armamentarium in the management of select EDA in the pediatric population. It allows for multidisciplinary collaboration between neurosurgeons and otolaryngologists for concomitant evacuation of the EDA and trephination of the frontal sinus. This approach is a feasible, safe, and effective minimally invasive technique that can be employed for the management of EDA secondary to diffuse sinusitis in the pediatric population.
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Affiliation(s)
- Hana Hallak
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael M McDowell
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Noel Jabbour
- Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Reema Padia
- Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stephanie Greene
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ian F Pollack
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Jumah F, Abou-Al-Shaar H, Mallela AN, Wiley CA, Lunsford LD. Gamma Knife Radiosurgery in the Management of Hypothalamic Glioma: A Case Report with Long-Term Follow-Up. Pediatr Neurosurg 2022; 57:118-126. [PMID: 34969032 DOI: 10.1159/000521732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 12/27/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Optic pathway/hypothalamic gliomas are rare pediatric brain tumors. The management paradigm for these challenging tumors includes chemotherapy, radiotherapy, or surgical resection, but the optimal management strategy remains elusive. Gamma knife radiosurgery (GKRS) has emerged as a promising treatment for such lesions as documented by a small number of cases in the literature. CASE PRESENTATION We present a rare case of hypothalamic glioma in a 13-year-old girl who was referred to our service due to growth of an incidentally diagnosed hypothalamic lesion following head injury at the age of 8 years. The lesion demonstrated hypointensity on T1- and hyperintensity on T2-weighted imaging without contrast enhancement. Given the growth of the lesion on serial imaging, a stereotactic biopsy was performed demonstrating low-grade glioma. The patient underwent GKRS treatment with a marginal dose of 15 Gy at 50% isodose line for a tumor volume of 2.2 mL. Annual radiological surveillance over the next 17 years demonstrated a gradual shrinkage of the lesion until it completely disappeared. The patient is currently a healthy 31-year-old female without any visual, endocrine, or neurocognitive deficits. CONCLUSION The outcome obtained after extended follow-up in our patient highlights the safety and efficacy of GKRS in the management of hypothalamic gliomas in pediatrics, which in turn can avoid potentially serious complications of surgery in this vulnerable patient population, especially in this sensitive location.
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Affiliation(s)
- Fareed Jumah
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, Rutgers-New Jersey Medical School, New Brunswick, New Jersey, USA,
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurological Surgery, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Clayton A Wiley
- Division of Neuropathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Mallela AN, Hect JL, Abou-Al-Shaar H, Akwayena E, Abel TJ. Stereotactic laser interstitial thermal therapy corpus callosotomy for the treatment of pediatric drug-resistant epilepsy. Epilepsia Open 2021; 7:75-84. [PMID: 34758204 PMCID: PMC8886067 DOI: 10.1002/epi4.12559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/21/2021] [Accepted: 10/31/2021] [Indexed: 11/14/2022] Open
Abstract
Objective Corpus callosotomy is a safe and effective procedure for reducing the frequency of drop attacks. MR‐guided laser interstitial thermal therapy (MRgLITT) offers a minimally invasive alternative to conventional open craniotomy for callosotomy. We hypothesized that MRgLITT callosotomy could be safely performed in pediatric patients with similar seizure control. Methods We present an institutional case series of 11 procedures in 10 patients for the treatment of drop attacks in drug‐refractory primary generalized epilepsy. MRgLITT was used for complete callosotomy, anterior two‐thirds, posterior, or ablation of residual callosal fibers following prior callosotomy (open or MRgLITT). We retrospectively reviewed clinical course, operative details, radiographic imaging, clinical outcomes, and complications. Results Operative time ranged from 4‐8 hours, and median hospitalization was 2 days. No complications were encountered. Among the 7 patients with at least 3 months of follow‐up, 71% experienced freedom from drop attacks at longest follow‐up and 57% of cases showed improvement in their other seizure semiologies as well (Engel Class II: 28%, Class III: 28%, Class IV: 43%). Significance MR‐guided LITT callosotomy is safe and effective modality in the management of pediatric patients with medically intractable epilepsy characterized by drop attacks. While this is among the largest pediatric series to date, further studies are required to delineate its safety and efficacy among such patients.
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Affiliation(s)
- Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emefa Akwayena
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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Zhang X, Habib A, Jaman E, Mallela AN, Amankulor NM, Zinn PO. Headlight and loupe-based fluorescein detection system in brain tumor surgery; a firstin-human experience. J Neurosurg Sci 2021; 67:374-379. [PMID: 34647714 DOI: 10.23736/s0390-5616.21.05469-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fluorescein is an agent that accumulates in areas of blood-brain barrier breakdown and is commonly used in neurosurgical oncology to assist with lesion localization and visualizing the extent of resection. It is considered to be cost-effective and has a favorable safety profile. Studies on the utilization of fluorescein demonstrate an improved extent of tumor resection and increased overall survival. Currently, fluorescein detection systems are all microscope based, leading to limitations such as decreased maneuverability, limited visualization of the entire operative field, and significant cost associated with obtaining and maintaining a neurosurgical operating microscope. METHODS Three consecutive craniotomy patients for tumor resection were included, and surgery was carried out under loupe fluorescence guidance using the ReVeal 450 System, and also a surgical microscope for comparison. RESULTS Loupe-mounted fluorescence system enabled excellent visualization of fluorescence in all three cases. CONCLUSIONS In this manuscript, we describe our experience with a loupe-mounted fluorescein detection system in 3 patients with malignant gliomas. We found that the loupe-mounted system offered excellent ability to visualize fluorescein fluorescence. Although loupe-mounted systems are not an alternative to surgical microscopes, they could be a useful surgical adjunct for superficial lesions and in low-middle income counties.
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Affiliation(s)
- Xiaoran Zhang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ahmed Habib
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emade Jaman
- School of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nduka M Amankulor
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pascal O Zinn
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA -
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Fogg DN, Mallela AN, Abou-Al-Shaar H, González-Martínez J. Robotic-assisted stereotactic drainage of cerebral abscess and placement of ventriculostomy. Br J Neurosurg 2021:1-4. [PMID: 34463595 DOI: 10.1080/02688697.2021.1969006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Robotic surgery has found increasing use in multiple subfields of neurosurgery. While the initial applications of stereotactic robotic surgery were for the placement of electrodes for extra-operative seizure monitoring, this technique has become increasingly relevant in other areas of neurosurgery. To the best of our knowledge, we report the first case of successful robotic surgery utilization to drain a cerebral abscess and place an external ventricular drain. CASE REPORT The authors demonstrate a novel use for stereotactic robotic assistance to drain a cerebral abscess and place ventriculostomy in a 74-year-old female patient who presented with a left basal ganglia Streptococcus intermedius abscess and concomitant ventriculitis. Drainage of a deep-seated abscess and placement of ventriculostomy was successfully performed in this patient without intraoperative difficulties or complications. The total operative time, including registration was 64 minutes and the estimated blood loss was 25 mL. The patient recovered well and was discharged to inpatient rehabilitation on postoperative day 19. CONCLUSIONS The use of robotic surgery to drain cerebral abscesses and place ventriculostomies is technically feasible and may potentially decrease operative time and increase accuracy and safety.
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Affiliation(s)
- David N Fogg
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Abou-Al-Shaar H, Faramand A, Zhang X, Mallela AN, Branstetter BF, Wiley CA, Lunsford LD. Chronic encapsulated expanding hematomas after stereotactic radiosurgery for intracranial arteriovenous malformations. J Neurosurg 2021; 136:492-502. [PMID: 34330101 DOI: 10.3171/2021.1.jns203476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral arteriovenous malformations (AVMs) are rare cerebral vascular lesions that are associated with high morbidity and mortality from hemorrhage; however, stereotactic radiosurgery (SRS) is a well-validated treatment modality. Few reports have delineated a subgroup of patients who develop delayed chronic encapsulated expanding hematomas (CEEHs) despite angiographic evidence of AVM obliteration following radiosurgery. In this report, the authors performed a retrospective review of more than 1000 radiosurgically treated intracranial AVM cases to delineate the incidence and management of this rare entity. METHODS Between 1988 and 2019, 1010 patients with intracranial AVM underwent Gamma Knife SRS at the University of Pittsburgh Medical Center. In addition to a review of a prospective institutional database, the authors performed a retrospective chart review of the departmental AVM database to specifically identify patients with CEEH. Pertinent clinical and radiological characteristics as well as patient outcomes were recorded and analyzed. RESULTS Nine hundred fifty patients with intracranial AVM (94%) had sufficient clinical follow-up for analysis. Of these, 6 patients with CEEH underwent delayed resection (incidence rate of 0.0045 event per person-year). These patients included 4 males and 2 females with a mean age of 45.3 ± 13.8 years at the time of initial SRS. Four patients had smaller AVM volumes (4.9-10 cm3), and 3 of them were treated with a single SRS procedure. Two patients had larger-volume AVMs (55 and 56 cm3), and both underwent multimodal management that included staged SRS and embolization. Time to initial recognition of the CEEH after initial SRS ranged between 66 and 243 months. The time between CEEH recognition and resection ranged from 2 to 9 months. Resection was required because of progressive neurological symptoms that correlated with imaging evidence of gradual hematoma expansion. All 6 patients had angiographically confirmed obliteration of their AVM. Pathology revealed a mixed chronicity hematoma with areas of fibrosed blood vessels and rare areas of neovascularization with immature blood vessels but no evidence of a persistent AVM. All 6 patients reported persistent clinical improvement after hematoma resection. CONCLUSIONS CEEH after SRS for AVM is a rare complication with an incidence rate of 0.0045 event per person-year over the authors' 30-year experience. When clinical symptoms progress and imaging reveals progressive enlargement over time, complete resection of a CEEH results in significant clinical recovery. Knowledge of this rare entity facilitates timely detection and eventual surgical intervention to achieve optimal outcomes.
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Affiliation(s)
| | | | | | | | | | - Clayton A Wiley
- 3Division of Neuropathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Mallela AN, Abou-Al-Shaar H, Nayar GM, Luy DD, Barot N, González-Martínez JA. Stereotactic Electroencephalography Implantation Through Nonautologous Cranioplasty: Proof of Concept. Oper Neurosurg (Hagerstown) 2021; 21:258-264. [PMID: 34293155 DOI: 10.1093/ons/opab260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/09/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Stereoelectroencephalography (SEEG) is an effective method to define the epileptogenic zone (EZ) in patients with medically intractable epilepsy. Typical placement requires passing and anchoring electrodes through native skull. OBJECTIVE To describe the successful placement of SEEG electrodes in patients without native bone. To the best of our knowledge, the use of SEEG in patients with nonautologous cranioplasties has not been described. METHODS We describe 3 cases in which SEEG was performed through nonautologous cranioplasty. The first is a 30-yr-old male with a titanium mesh cranioplasty following a left pterional craniotomy for aneurysm clipping. The second is a 51-yr-old female who previously underwent lesionectomy of a ganglioglioma with mesh cranioplasty and subsequent recurrence of her seizures. The third is a 31-yr-old male with a polyether ether ketone cranioplasty following decompressive hemicraniectomy for trauma. RESULTS SEEG was performed successfully in all three cases without intraoperative difficulties or complications and with excellent electroencephalogram recording and optimal localization of the seizure focus. The EZ was successfully localized in all three patients. There were no limitations related to drilling or inserting the guiding bolt/electrode through the nonautologous cranioplasties. CONCLUSION SEEG through nonautologous cranioplasties was clinically feasible, safe, and effective in our series. The presence of nonautologous bone cranioplasty should not preclude such patients from undergoing SEEG explorations.
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Affiliation(s)
- Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gautam M Nayar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Diego D Luy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Niravkumar Barot
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jorge A González-Martínez
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Wei Z, Mallela AN, Faramand A, Niranjan A, Lunsford LD. Long-term survival in patients with long-segment complex meningiomas occluding the dural venous sinuses: illustrative cases. Journal of Neurosurgery: Case Lessons 2021; 1:CASE21116. [PMID: 35855015 PMCID: PMC9245851 DOI: 10.3171/case21116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/03/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Invasive sagittal sinus meningiomas are difficult tumors to cure by resection alone. Stereotactic radiosurgery (SRS) can be used as an adjuvant management strategy to improve tumor control after incomplete resection. OBSERVATIONS The authors reported the long-term retrospective follow-up of two patients whose recurrent parasagittal meningiomas eventually occluded their superior sagittal sinus. Both patients underwent staged radiosurgery and fractionated radiation therapy to achieve tumor control that extended to 20 years after their initial surgery. After initial subtotal resection of meningiomas that had invaded major cerebral venous sinuses, adjuvant radiosurgery was performed to enhance local tumor control. Over time, adjacent tumor progression required repeat SRS and fractionated radiation therapy to boost long-term tumor response. Staged multimodality intervention led to extended survival in these patients with otherwise unresectable meningiomas. LESSONS Multimodality management with radiosurgery and fractionated radiation therapy was associated with long-term survival of two patients with otherwise surgically incurable and invasive meningiomas of the dural venous sinuses.
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