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Belkhir JR, Pease M, McCarthy DJ, Legarretta A, Mittal AM, Crago EA, Gross BA, Lang MJ. Subarachnoid Hemorrhage Outcomes in an Endovascular Right of First Refusal Neurosurgical Environment. World Neurosurg 2024; 181:e524-e532. [PMID: 37879435 PMCID: PMC10842161 DOI: 10.1016/j.wneu.2023.10.091] [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: 08/17/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Randomized controlled trials demonstrate that endovascular techniques yield improved outcomes compared with microsurgical approaches. However, not all patients are suitable candidates for endovascular management. This study aimed to determine if healthy patients managed microsurgically could achieve functional outcomes comparable to patients managed endovascularly. METHODS Patients treated for ruptured aneurysmal subarachnoid hemorrhage at 2 level 1 stroke centers from January 2012 through December 2020 were retrospectively reviewed. All cases were evaluated in an endovascular right of first refusal neurosurgical environment. We collected relevant clinical and follow-up data and created a generalized linear model to identify differences between patients treated endovascularly versus microsurgically. A propensity score model accounting for these differences was used to predict patient outcomes. Functional outcomes were independently assessed using the modified Rankin Scale (mRS) with good functional outcome defined as modified Rankin Scale score <3. RESULTS The study included 588 patients (211 microsurgical, 377 endovascular); median age was 58 years (interquartile range: 40-86 years); in-hospital mortality was 13%. Age, aneurysm size, and aneurysm location significantly predicted treatment modality (all P < 0.05). After greedy-type matching (210 microsurgical, 210 endovascular), patients managed microsurgically were less likely to be discharged home (odds ratio = 0.6, 95% confidence interval 0.4-0.9, P = 0.01). Functional differences disappeared over time; patients in the 2 treatment arms had similar functional outcomes at 3 months (odds ratio = 1.1, 95% confidence interval 0.7-1.8, P = 0.66) and 1 year after subarachnoid hemorrhage (odds ratio = 1.3, 95% confidence interval 0.8-2.1, P = 0.38). CONCLUSIONS In an endovascular right of first refusal neurosurgical environment, practitioners can treat patients who are not good endovascular candidates microsurgically and achieve functional outcomes comparable to patients managed endovascularly.
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Affiliation(s)
- J Raouf Belkhir
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Matthew Pease
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David J McCarthy
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew Legarretta
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aditya M Mittal
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Elizabeth A Crago
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Wei Z, Luy DD, Jose S, Deng H, Yavan S, Worrell S, Belkhir JR, Tang LW, Niranjan A, Lunsford LD. Single-Session Gamma Knife Radiosurgery for Patients With 20 or More Brain Metastases. Neurosurgery 2023; 93:857-866. [PMID: 37018427 DOI: 10.1227/neu.0000000000002482] [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: 09/16/2022] [Accepted: 02/08/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is a widely accepted treatment modality for brain metastases. The role of SRS in patients with higher numbers of metastases remains controversial. OBJECTIVES To define outcomes in patients with ≥20 brain metastases managed using single-session SRS. METHODS This single-institution retrospective cohort study studied 75 patients (26 non-small-cell lung cancer, 21 small-cell lung cancer, 14 breast cancer, and 14 melanoma) undergoing single-session SRS. The median number of tumors per patient was 24, and the median cumulative tumor volume was 3.70 cc. The median margin dose prescribed to each individual tumor was 16 Gy. The median integral cranial dose was 5492 mJ. The median beam on time was 160 minutes. Univariate and multivariate analyses were performed with significance set at P < .05. RESULTS The median overall survival after SRS was 8.8 months (patients with non-small-cell lung cancer), 4.6 months (patients with small-cell lung cancer), 11.3 months (patients with breast cancer), and 4.1 months (patients with melanoma). Primary cancer type, number of brain metastases, and concurrent immunotherapy were significant factors in predicting survival. Local tumor control rate per patient was 97.3% and 94.6% at 6 and 12 months after SRS, respectively. Thirty-six patients underwent additional SRS for new tumor development with a median time after SRS of 5 months. Three patients experienced adverse radiation events. CONCLUSION Single-session SRS is a well-tolerated palliative treatment option even in patients with ≥20 brain metastases, achieving local control rate >90% with low risks of neurotoxicity while continuing concurrent systemic oncological care.
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Affiliation(s)
- Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
- University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Diego D Luy
- University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Shalini Jose
- University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Sila Yavan
- University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Stephen Worrell
- University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - J Raouf Belkhir
- University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Lilly W Tang
- University of Pittsburgh School of Medicine, 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
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Wei Z, Luy D, Yavan S, Jose S, Worrell S, Belkhir JR, Deng H, Niranjan A, Lunsford LD. RADT-04. SINGLE SESSION GAMMA KNIFE RADIOSURGERY TO TREAT PATIENTS WITH 20 OR MORE BRAIN METASTASES. Neuro Oncol 2022. [PMCID: PMC9661157 DOI: 10.1093/neuonc/noac209.194] [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] [Indexed: 11/16/2022] Open
Abstract
Abstract
BACKGROUND
Stereotactic Radiosurgery (SRS) has become a primary management option for brain metastases (BMs). This present study aims to review outcomes in patients with ≥ 20 BMs treated in a single session SRS and to identify predictors of local tumor control (LTC) and overall survival (OS).
METHODS
We identified 75 patients including 26 non-small cell lung cancer (NSCLC), 21 small cell lung cancer (SCLC), 14 breast cancer (BC), and 14 melanoma patients who underwent SRS for ≥ 20 BMs between 2014 and 2020. The median number of tumors was 24 (range 20 – 52), and the median cumulative tumor volume was 3.70 cc (0.13 – 62.49 cc). The median margin dose was 16 Gy (14 – 20 Gy). Median skull integral dose was 5492 mJ (range 1372 – 11243 mJ). The median treatment time for each session was 160 min. Outcome variables were assessed using univariate and multivariate analyses with p < 0.05.
RESULTS
Median OS after SRS was 5.8 months (range 0.1 – 73.2 months). Primary cancer type and concurrent immunotherapy were significant predictive factors for patient OS after SRS (p = 0.01, 0.05, and 0.02, respectively). LTC rate at 6 and 12 months after SRS was 95.7% and 83.7%, respectively. Thirty (40.0%) patients underwent additional SRS and 3 patients (4%) received post-SRS WBRT due to distant tumor recurrence. The median time to distant recurrence was 5 months (range 2-28 months). SRS-induced adverse radiation effects (ARE) events were observed in 3 patients (4.0%; 1 NSCLC, 1 SCLC, and 1 melanoma).
CONCLUSIONS
Our results suggest that patients with ≥ 20 BMs can be safely treated with SRS with an excellent LTC rate and a low risk of ARE. Newly developed BMs can be treated with repeat SRS. This single-session SRS allows patients to proceed with systemic cancer care without interruption.
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Affiliation(s)
- Zhishuo Wei
- University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Diego Luy
- University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Sila Yavan
- University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Shalini Jose
- University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Stephen Worrell
- University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - J Raouf Belkhir
- University of Pittsburgh School of Medicine , Pittsburgh , USA
| | - Hansen Deng
- University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Ajay Niranjan
- University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - L Dade Lunsford
- University of Pittsburgh Medical Center , Pittsburgh, PA , USA
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Belkhir JR, Fitch WT, Garcea FE, Chernoff BL, Sims MH, Navarrete E, Haber S, Paul DA, Smith SO, Pilcher WH, Mahon BZ. Direct electrical stimulation evidence for a dorsal motor area with control of the larynx. Brain Stimul 2020; 14:110-112. [PMID: 33217608 DOI: 10.1016/j.brs.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/19/2020] [Accepted: 11/12/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- J Raouf Belkhir
- Department of Psychology, Carnegie Mellon University, 5000 Forbes Ave, Pittsburgh, PA, 15213, USA; Carnegie Mellon Neuroscience Institute, Carnegie Mellon University, 5000 Forbes Ave, Pittsburgh, PA, 15213, USA
| | - W Tecumseh Fitch
- Department of Behavioral and Cognitive Biology, Faculty of Life Sciences, University of Vienna, Althanstrasse 14, 1090, Vienna, Austria
| | - Frank E Garcea
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Benjamin L Chernoff
- Department of Psychology, Carnegie Mellon University, 5000 Forbes Ave, Pittsburgh, PA, 15213, USA
| | - Max H Sims
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Eduardo Navarrete
- Dipartimento di Psicologia Dello Sviluppo e Della Socializzazione, Università di Padova, Via Venezia 8, 35131, Padova, Italy
| | - Sam Haber
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - David A Paul
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Susan O Smith
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Webster H Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Bradford Z Mahon
- Department of Psychology, Carnegie Mellon University, 5000 Forbes Ave, Pittsburgh, PA, 15213, USA; Carnegie Mellon Neuroscience Institute, Carnegie Mellon University, 5000 Forbes Ave, Pittsburgh, PA, 15213, USA; Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA; Department of Neurology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
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Belkhir JR. Harrison, S. The Impulse to Gesture: Where Language, Minds, and Bodies Intersect. Perception 2019. [DOI: 10.1177/0301006619868634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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