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Huguenard AL, Johnson GW, Osbun JW, Dacey RG, Braverman AC. Natural history and growth rate of intracranial aneurysms in Loeys-Dietz syndrome: implications for treatment. J Neurosurg 2024; 140:1381-1388. [PMID: 37948688 DOI: 10.3171/2023.8.jns23733] [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: 04/02/2023] [Accepted: 08/31/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Loeys-Dietz syndrome (LDS) is a heritable aortopathy associated with craniofacial abnormalities and dilatation and dissection of the aorta and its branches, as well as increased risk for intracranial aneurysms (ICAs). Given the rarity of the disease, the authors aimed to better define the natural history and role for the treatment for ICAs in these patients. METHODS The medical records of 83 patients with LDS were retrospectively reviewed to obtain clinical and genetic history and vascular imaging of the aorta, aortic branches, and intracranial vessels. Serial radiology reports and cervical and intracranial vascular images were reviewed to determine presence, location, and size of ICAs. RESULTS In total, 55 patients (66.3%) had at least two screening intracranial vascular examinations, and 19 (22.9%) had at least 1 ICA detected. Aneurysms were typically small (mean ± SD 3.2 ± 1.8 mm). ICAs were most often located in the cavernous carotid, followed by the ophthalmic and anterior cerebral artery vessels. The rate of ICA growth was 0.43 ± 0.53 mm/year, similar to that of the general population. Three patients underwent intervention for an ICA, with 1 procedure complicated by stroke and resulting in transient hemiparesis. Several illustrative cases detail the authors' experience with ICA growth, de novo aneurysm formation, and ICA intervention in this rare patient population. CONCLUSIONS ICAs in patients with LDS are common, are frequently small, and have a growth rate similar to that of unruptured ICAs in the general population. More aggressive or earlier intervention for asymptomatic ICAs identified in LDS patients compared with the general population is likely unwarranted based on the authors' experience at their institution.
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Affiliation(s)
- Anna L Huguenard
- 1Department of Neurosurgery, Washington University in St. Louis, Missouri; and
| | - Gabrielle W Johnson
- 1Department of Neurosurgery, Washington University in St. Louis, Missouri; and
| | - Joshua W Osbun
- 1Department of Neurosurgery, Washington University in St. Louis, Missouri; and
| | - Ralph G Dacey
- 1Department of Neurosurgery, Washington University in St. Louis, Missouri; and
| | - Alan C Braverman
- 2Department of Medicine, Cardiovascular Division, Washington University in St. Louis, Missouri
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2
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Johanns TM, Garfinkle EAR, Miller KE, Livingstone AJ, Roberts KF, Rao Venkata LP, Dowling JL, Chicoine MR, Dacey RG, Zipfel GJ, Kim AH, Mardis ER, Dunn GP. Integrating multisector molecular characterization into personalized peptide vaccine design for patients with newly diagnosed glioblastoma. Clin Cancer Res 2024:743147. [PMID: 38639919 DOI: 10.1158/1078-0432.ccr-23-3077] [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: 10/16/2023] [Revised: 01/18/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE Glioblastoma (GBM) patient outcomes remain poor despite multimodality treatment with surgery, radiation, and chemotherapy. There are few immunotherapy options due to the lack of tumor immunogenicity. Several clinical trials have reported promising results with cancer vaccines. To date, studies have used data from a single tumor site to identify targetable antigens, but this approach limits the antigen pool and is antithetical to the heterogeneity of GBM. We have implemented multisector sequencing to increase the pool of neoantigens across the GBM genomic landscape that can be incorporated into personalized peptide vaccines called NeoVax. PATIENTS AND METHODS Here, we report the findings of four subjects enrolled onto the NeoVax clinical trial (NCT0342209). RESULTS Immune reactivity to NeoVax neoantigens was assessed in peripheral blood mononuclear cells (PBMCs) pre- and post-NeoVax for subjects 1-3 using IFNg-ELISPOT assay. A statistically significant increase in IFNg producing T cells at the post-NeoVax time point for several neoantigens was observed. Furthermore, a post-NeoVax tumor biopsy was obtained from subject 3 and, upon evaluation, revealed evidence of infiltrating, clonally expanded T cells. CONCLUSIONS Collectively, our findings suggest NeoVax did stimulate expansion of neoantigen-specific effector T cells and provide encouraging results to aid in the development of future neoantigen vaccine-based clinical trials in patients with GBM. Herein, we demonstrate the feasibility of incorporating multisector sampling in cancer vaccine design and provide information on the clinical applicability of clonality, distribution, and immunogenicity of the neoantigen landscape in GBM patients.
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Affiliation(s)
- Tanner M Johanns
- Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | | | | | | | - Kaleigh F Roberts
- Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | | | - Joshua L Dowling
- Washington University in St. Louis School of Medicine, United States
| | | | - Ralph G Dacey
- Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - Gregory J Zipfel
- Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Albert H Kim
- Washington University in St. Louis School of Medicine, St Louis, MO, United States
| | | | - Gavin P Dunn
- Massachusetts General Hospital, Boston, MA, United States
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Coxon AT, Huguenard AL, Chatterjee AR, Dacey RG. A challenging case of recurrent and progressive fusiform anterior circulation intracranial aneurysms: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE22497. [PMID: 36794734 PMCID: PMC10550598 DOI: 10.3171/case22497] [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: 11/15/2022] [Accepted: 12/09/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND Intracranial fusiform aneurysms are circumferential dilations of cerebral arteries that can lead to complications including ischemic stroke due to vessel occlusion, subarachnoid hemorrhage, or intracerebral hemorrhage. Treatment options for fusiform aneurysms have expanded significantly in recent years. Microsurgical treatment options include proximal and distal surgical occlusion and microsurgical trapping of the aneurysm, usually in association with high-flow bypass procedures. Endovascular treatment options include the placement of coils and/or flow diverters. OBSERVATIONS Here the authors report a case of aggressive surveillance and treatment of a man with multiple progressive, recurrent, and de novo fusiform aneurysms of the left anterior cerebral circulation over 16 years. Because the long-term course of his treatment coincided with the recent expansion of endovascular treatment options, he underwent every type of treatment listed above. LESSONS This case demonstrates the wide range of therapeutic options for fusiform aneurysms and how the treatment model for these lesions has evolved.
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Affiliation(s)
| | | | - Arindam R. Chatterjee
- Departments of Neurosurgery
- Radiology, and
- Neurology, Washington University, St. Louis, Missouri
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4
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Li YD, Coxon AT, Huang J, Abraham CD, Dowling JL, Leuthardt EC, Dunn GP, Kim AH, Dacey RG, Zipfel GJ, Evans J, Filiput EA, Chicoine MR. Neoadjuvant stereotactic radiosurgery for brain metastases: a new paradigm. Neurosurg Focus 2022; 53:E8. [PMID: 36321291 PMCID: PMC10602665 DOI: 10.3171/2022.8.focus22367] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/19/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE For patients with surgically accessible solitary metastases or oligometastatic disease, treatment often involves resection followed by postoperative stereotactic radiosurgery (SRS). This strategy has several potential drawbacks, including irregular target delineation for SRS and potential tumor "seeding" away from the resection cavity during surgery. A neoadjuvant (preoperative) approach to radiation therapy avoids these limitations and offers improved patient convenience. This study assessed the efficacy of neoadjuvant SRS as a new treatment paradigm for patients with brain metastases. METHODS A retrospective review was performed at a single institution to identify patients who had undergone neoadjuvant SRS (specifically, Gamma Knife radiosurgery) followed by resection of a brain metastasis. Kaplan-Meier survival and log-rank analyses were used to evaluate risks of progression and death. Assessments were made of local recurrence and leptomeningeal spread. Additionally, an analysis of the contemporary literature of postoperative and neoadjuvant SRS for metastatic disease was performed. RESULTS Twenty-four patients who had undergone neoadjuvant SRS followed by resection of a brain metastasis were identified in the single-institution cohort. The median age was 64 years (range 32-84 years), and the median follow-up time was 16.5 months (range 1 month to 5.7 years). The median radiation dose was 17 Gy prescribed to the 50% isodose. Rates of local disease control were 100% at 6 months, 87.6% at 12 months, and 73.5% at 24 months. In 4 patients who had local treatment failure, salvage therapy included repeat resection, laser interstitial thermal therapy, or repeat SRS. One hundred thirty patients (including the current cohort) were identified in the literature who had been treated with neoadjuvant SRS prior to resection. Overall rates of local control at 1 year after neoadjuvant SRS treatment ranged from 49% to 91%, and rates of leptomeningeal dissemination from 0% to 16%. In comparison, rates of local control 1 year after postoperative SRS ranged from 27% to 91%, with 7% to 28% developing leptomeningeal disease. CONCLUSIONS Neoadjuvant SRS for the treatment of brain metastases is a novel approach that mitigates the shortcomings of postoperative SRS. While additional prospective studies are needed, the current study of 130 patients including the summary of 106 previously published cases supports the safety and potential efficacy of preoperative SRS with potential for improved outcomes compared with postoperative SRS.
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Affiliation(s)
- Yuping Derek Li
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
| | - Andrew T. Coxon
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Christopher D. Abraham
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Joshua L. Dowling
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Eric C. Leuthardt
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Gavin P. Dunn
- Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Albert H. Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Ralph G. Dacey
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Gregory J. Zipfel
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - John Evans
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
| | - Eric A. Filiput
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R. Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
- Department of Neurosurgery, University of Missouri, Columbia, Missouri
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Yahanda AT, Rich KM, Dacey RG, Zipfel GJ, Dunn GP, Dowling JL, Smyth MD, Leuthardt EC, Limbrick DD, Honeycutt J, Sutherland GR, Jensen RL, Evans J, Chicoine MR. Survival After Resection of Newly-Diagnosed Intracranial Grade II Ependymomas: An Initial Multicenter Analysis and the Logistics of Intraoperative Magnetic Resonance Imaging. World Neurosurg 2022; 167:e757-e769. [PMID: 36028106 DOI: 10.1016/j.wneu.2022.08.077] [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: 08/07/2022] [Accepted: 08/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To identify factors, including the use of intraoperative magnetic resonance imaging (iMRI), impacting overall survival (OS) and progression-free survival (PFS) after resections of newly diagnosed intracranial grade II ependymomas performed across 4 different institutions. METHODS Analyses of a multicenter mixed retrospective/prospective database assessed the impact of patient, treatment, and tumor characteristics on OS and PFS. iMRI workflow and logistics were also outlined. RESULTS Forty-three patients were identified (mean age 25.4 years, mean follow-up 52.8 months). The mean OS was 52.8 ± 44.7 months. Univariate analyses failed to identify prognostic factors associated with OS, likely due to relatively shorter follow-up time for this less aggressive glioma subtype. The mean PFS was 43.7 ± 39.8 months. Multivariate analyses demonstrated that gross-total resection was associated with prolonged PFS compared to both subtotal resection (STR) (P = 0.005) and near-total resection (P = 0.01). Infratentorial location was associated with improved PFS compared to supratentorial location (P = 0.04). Log-rank analyses of Kaplan-Meier survival curves showed that increasing extent of resection (EOR) led to improved OS specifically for supratentorial tumors (P = 0.02) and improved PFS for all tumors (P < 0.001). Thirty cases (69.8%) utilized iMRI, of which 12 (27.9%) involved additional resection after iMRI. Of these, 8/12 (66.7%) resulted in gross-total resection, while 2/12 (16.7%) were near-total resection and 2/12 (16.7%) were subtotal resection. iMRI was not an independent prognosticator of PFS (P = 0.72). CONCLUSIONS Greater EOR and infratentorial location were associated with increased PFS for grade II ependymomas. Greater EOR was associated with longer OS only for supratentorial tumors. A longer follow-up is needed to establish prognostic factors for this cohort, including use of iMRI.
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Affiliation(s)
- Alexander T Yahanda
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Gavin P Dunn
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Joshua L Dowling
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Matthew D Smyth
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Eric C Leuthardt
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - John Honeycutt
- Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Garnette R Sutherland
- Department of Neurological Surgery, University of Calgary School of Medicine, Calgary, Alberta, Canada
| | - Randy L Jensen
- Department of Neurological Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John Evans
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Beaumont TL, Limbrick DD, Patel B, Chicoine MR, Rich KM, Dacey RG. Surgical management of colloid cysts of the third ventricle: a single-institution comparison of endoscopic and microsurgical resection. J Neurosurg 2022; 137:905-913. [PMID: 35148502 DOI: 10.3171/2021.11.jns211317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/30/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Colloid cysts of the third ventricle are histologically benign lesions that can cause obstructive hydrocephalus and death. Historically, colloid cysts have been removed by open microsurgical approaches. More recently, minimally invasive endoscopic and port-based techniques have offered decreased complications and length of stay, with improved patient satisfaction. METHODS A single-center retrospective analysis of patients with colloid cysts who underwent surgery at a large tertiary care hospital was performed. The cohort was assessed based on the surgical approach, comparing endoscopic resection to open microsurgical resection. The primary endpoint was rate of perioperative complications. Univariate analysis was used to assess several procedure-related variables and the cost of treatment. Multivariate analysis was used to assess predictors of perioperative complications. Total inpatient cost for each case was extracted from the health system financial database. RESULTS The study included 78 patients with colloid cysts who underwent resection either via an endoscopic approach (n = 33) or through a craniotomy (n = 45) with an interhemispheric-transcallosal or transcortical-transventricular approach. Nearly all patients were symptomatic, and half had obstructive hydrocephalus. Endoscopic resection was associated with reduced operative time (3.2 vs 4.9 hours, p < 0.001); lower complication rate (6.1% vs 33.1%, p = 0.009); reduced length of stay (4.1 vs 8.9 days, p < 0.001); and improved discharge to home (100% vs 75.6%, p = 0.008) compared to microsurgical resection. Coagulated residual cyst wall remnants were more common after endoscopic resection (63.6% vs 19.0%, p < 0.001) although this was not associated with a significantly increased rate of reoperation for recurrence. The mean follow-up was longer in the microsurgical resection group (3.1 vs 4.9 years, p = 0.016). The total inpatient cost of endoscopic resection was, on average, one-half (47%) that of microsurgical resection. When complications were encountered, the total inpatient cost of microsurgical resection was 4 times greater than that of endoscopic resection where no major complications were observed. The increased cost-effectiveness of endoscopic resection remained during reoperation. CONCLUSIONS Endoscopic resection of colloid cysts of the third ventricle offers a significant reduction in perioperative complications when compared to microsurgical resection. Endoscopic resection optimizes nearly all procedure-related variables compared to microsurgical resection, and reduces total inpatient cost by > 50%. However, endoscopic resection is associated with a significantly increased likelihood of residual coagulated cyst wall remnants that could increase the rate of reoperation for recurrence. Taken together, endoscopic resection represents a safe and effective minimally invasive approach for removal of colloid cysts.
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Huguenard *AL, Johnson GW, Desai RR, Osbun JW, Dacey RG, Braverman AC. Relationship between phenotypic features in Loeys-Dietz syndrome and the presence of intracranial aneurysms. J Neurosurg 2022; 138:1385-1392. [PMID: 36308480 DOI: 10.3171/2022.9.jns221373] [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: 06/14/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Loeys-Dietz syndrome (LDS) is a rare autosomal dominant condition characterized by aneurysms of the aorta, aortic branches, and intracranial arteries; skeletal and cutaneous abnormalities; and craniofacial malformations. Previous authors have reported that higher craniofacial severity index (CFI) scores, which indicate more severe craniofacial abnormalities, correlate with the severity of aortic aneurysm pathology. However, the association between syndromic features and the formation of intracranial aneurysms in LDS patients has yet to be determined. In this study, the authors evaluate the incidence of phenotypic abnormalities, craniofacial features, and Chiari malformation type I (CM-I) in a large LDS cohort and explore possible risk factors for the development of intracranial aneurysms.
METHODS
This was a retrospective cohort study of all patients with LDS who had been seen at the Marfan Syndrome and Aortopathy Center at Washington University School of Medicine in St. Louis in 2010–2022. Medical records were reviewed to obtain demographic, clinical, and radiographic data. The prevalence of craniofacial, skeletal, and cutaneous pathologies was determined. Bivariate logistic regression was performed to identify possible risk factors for the formation of an intracranial aneurysm.
RESULTS
Eighty-one patients with complete medical records and intracranial vascular imaging were included in the analysis, and 18 patients (22.2%) had at least 1 intracranial aneurysm. Patients frequently demonstrated the thin or translucent skin, doughy skin texture, hypertelorism, uvular abnormalities, and joint hypermobility typical of LDS. CM-I was common, occurring in 7.4% of the patients. Importantly, the patients with intracranial aneurysms were more likely to have CM-I (22.2%) than those without intracranial aneurysms (3.2%). The mean CFI score in the cohort with available data was 1.81, with higher means in the patients with the TGFBR1 or TGFBR2 disease-causing variants (2.05 and 3.30, respectively) and lower in the patients with the SMAD3, TGFB2, or TGFB3 pathogenic variants (CFI < 1). No significant CFI difference was observed in patients with or without intracranial aneurysms (2.06 vs 1.74, p = 0.61).
CONCLUSIONS
CM-I, and not the CFI, is significantly associated with the presence of intracranial aneurysms in patients with LDS. Surveillance for intracranial aneurysms is essential in all patients with LDS and should not be limited to those with severe phenotypes. Long-term monitoring studies will be necessary to determine whether a correlation between craniofacial abnormalities and adverse outcomes from intracranial aneurysms (growth, intervention, or rupture) exists.
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Affiliation(s)
| | | | - Rupen R. Desai
- Department of Neurosurgery, Washington University in St. Louis; and
| | - Joshua W. Osbun
- Department of Neurosurgery, Washington University in St. Louis; and
| | - Ralph G. Dacey
- Department of Neurosurgery, Washington University in St. Louis; and
| | - Alan C. Braverman
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, Missouri
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Han RH, Johnson GW, Coxon AT, Gupta VP, Richards MJ, Lancia S, Salter A, Miller-Thomas MM, Dacey RG, Zipfel GJ, Osbun JW. Comparative Effectiveness of Management by Surgical Resection vs Observation for Cerebral Cavernous Malformations: A Matched Propensity Score Analysis. Neurosurgery Open 2022. [DOI: 10.1227/neuopn.0000000000000011] [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: 11/19/2022] Open
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9
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Affiliation(s)
- Anna L Huguenard
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO. (A.L.H., G.W.J., J.W.O., R.G.D.)
| | - Gabrielle W Johnson
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO. (A.L.H., G.W.J., J.W.O., R.G.D.)
| | - Joshua W Osbun
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO. (A.L.H., G.W.J., J.W.O., R.G.D.)
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO. (A.L.H., G.W.J., J.W.O., R.G.D.)
| | - Alan C Braverman
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (A.C.B.)
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Wang AZ, Bowman-Kirigin JA, Desai R, Kang LI, Patel PR, Patel B, Khan SM, Bender D, Marlin MC, Liu J, Osbun JW, Leuthardt EC, Chicoine MR, Dacey RG, Zipfel GJ, Kim AH, DeNardo DG, Petti AA, Dunn GP. Single-cell profiling of human dura and meningioma reveals cellular meningeal landscape and insights into meningioma immune response. Genome Med 2022; 14:49. [PMID: 35534852 PMCID: PMC9088131 DOI: 10.1186/s13073-022-01051-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 04/21/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Recent investigations of the meninges have highlighted the importance of the dura layer in central nervous system immune surveillance beyond a purely structural role. However, our understanding of the meninges largely stems from the use of pre-clinical models rather than human samples. METHODS Single-cell RNA sequencing of seven non-tumor-associated human dura samples and six primary meningioma tumor samples (4 matched and 2 non-matched) was performed. Cell type identities, gene expression profiles, and T cell receptor expression were analyzed. Copy number variant (CNV) analysis was performed to identify putative tumor cells and analyze intratumoral CNV heterogeneity. Immunohistochemistry and imaging mass cytometry was performed on selected samples to validate protein expression and reveal spatial localization of select protein markers. RESULTS In this study, we use single-cell RNA sequencing to perform the first characterization of both non-tumor-associated human dura and primary meningioma samples. First, we reveal a complex immune microenvironment in human dura that is transcriptionally distinct from that of meningioma. In addition, we characterize a functionally diverse and heterogenous landscape of non-immune cells including endothelial cells and fibroblasts. Through imaging mass cytometry, we highlight the spatial relationship among immune cell types and vasculature in non-tumor-associated dura. Utilizing T cell receptor sequencing, we show significant TCR overlap between matched dura and meningioma samples. Finally, we report copy number variant heterogeneity within our meningioma samples. CONCLUSIONS Our comprehensive investigation of both the immune and non-immune cellular landscapes of human dura and meningioma at single-cell resolution builds upon previously published data in murine models and provides new insight into previously uncharacterized roles of human dura.
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Affiliation(s)
- Anthony Z Wang
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jay A Bowman-Kirigin
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
| | - Rupen Desai
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
| | - Liang-I Kang
- Division of Anatomic and Molecular Pathology, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Pujan R Patel
- Washington University School of Medicine, St. Louis, MO, USA
| | - Bhuvic Patel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
| | - Saad M Khan
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
| | - Diane Bender
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
| | - M Caleb Marlin
- Arthritis & Clinical Immunology Human Phenotyping Core, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Jingxian Liu
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
- McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO, USA
| | - Joshua W Osbun
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
| | - Eric C Leuthardt
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
| | - Albert H Kim
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA
| | - David G DeNardo
- Division of Oncology-Molecular Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Allegra A Petti
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA.
- Brain Tumor Center, Washington University School of Medicine/Siteman Cancer Center, St. Louis, USA.
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Gavin P Dunn
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA.
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11
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Cler SJ, Dunn GP, Zipfel GJ, Dacey RG, Chicoine M. A Low Subfrontal Dural Opening for Operative Management of Anterior Skull Base Lesions. J Neurol Surg B Skull Base 2022; 84:201-209. [PMID: 37180868 PMCID: PMC10171938 DOI: 10.1055/a-1774-6281] [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: 09/12/2021] [Accepted: 02/14/2022] [Indexed: 10/19/2022] Open
Abstract
Introduction
A low subfrontal dural opening technique that limits brain manipulation was assessed in patients that underwent frontotemporal approaches for anterior fossa lesions.
Methods
A retrospective review was performed for cases using a low subfrontal dural opening including characterization of demographics, lesion size and location, neurological and ophthalmological assessments, clinical course, and imaging findings.
Results
A low subfrontal dural opening was performed in 23 patients (17F, 6M), median age of 53 years (range 23-81) with median follow-up duration of 21.9 months (range 6.2-67.1). Lesions included 22 meningiomas (9 anterior clinoid, 12 tuberculum sellae, and 1 sphenoid wing), 1 unruptured internal carotid artery aneurysm clipped during a meningioma resection, and 1 optic nerve cavernous malformation. Maximal possible resection was achieved in all cases including gross total resection in 16/22 (72.7%), near total in 1/22 (4.5%), and subtotal in 5/22 (22.7%) in which tumor involvement of critical structures limited complete resection. Eighteen patients presented with vision loss; 11 (61%) improved postoperatively, 3 (17%) were stable, and 4 (22%) worsened. The mean ICU stay and time to discharge was 1.3 days (range 0-3) and 3.8 days (range 2-8).
Conclusions
A low subfrontal dural opening for approaches to the anterior fossa can be performed with minimal brain exposure, early visualization of the optico-carotid cistern for cerebrospinal fluid release, minimizing need for fixed brain retraction and Sylvian fissure dissection. This technique can potentially reduce surgical risk and provide excellent exposure for anterior skull base lesions with favorable extent of resection, visual recovery, and complication rates.
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Affiliation(s)
- Samuel J Cler
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Gavin P Dunn
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Gregory J Zipfel
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Ralph G Dacey
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Michael Chicoine
- Neurosurgery, Washington University in Saint Louis, Saint Louis, United States
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12
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Akbari SHA, Rizvi AA, CreveCoeur TS, Han RH, Greenberg JK, Torner J, Brockmeyer DL, Wellons JC, Leonard JR, Mangano FT, Johnston JM, Shah MN, Iskandar BJ, Ahmed R, Tuite GF, Kaufman BA, Daniels DJ, Jackson EM, Grant GA, Powers AK, Couture DE, Adelson PD, Alden TD, Aldana PR, Anderson RCE, Selden NR, Bierbrauer K, Boydston W, Chern JJ, Whitehead WE, Dauser RC, Ellenbogen RG, Ojemann JG, Fuchs HE, Guillaume DJ, Hankinson TC, O'Neill BR, Iantosca M, Oakes WJ, Keating RF, Klimo P, Muhlbauer MS, McComb JG, Menezes AH, Khan NR, Niazi TN, Ragheb J, Shannon CN, Smith JL, Ackerman LL, Jea AH, Maher CO, Narayan P, Albert GW, Stone SSD, Baird LC, Gross NL, Durham SR, Greene S, McKinstry RC, Shimony JS, Strahle JM, Smyth MD, Dacey RG, Park TS, Limbrick DD. Socioeconomic and demographic factors in the diagnosis and treatment of Chiari malformation type I and syringomyelia. J Neurosurg Pediatr 2021:1-10. [PMID: 34861643 DOI: 10.3171/2021.9.peds2185] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to assess the social determinants that influence access and outcomes for pediatric neurosurgical care for patients with Chiari malformation type I (CM-I) and syringomyelia (SM). METHODS The authors used retro- and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM-I and SM who received surgical treatment and had at least 1 year of follow-up data. Race, ethnicity, and insurance status were used as comparators for preoperative, treatment, and postoperative characteristics and outcomes. RESULTS A total of 637 patients met inclusion criteria, and race or ethnicity data were available for 603 (94.7%) patients. A total of 463 (76.8%) were non-Hispanic White (NHW) and 140 (23.2%) were non-White. The non-White patients were older at diagnosis (p = 0.002) and were more likely to have an individualized education plan (p < 0.01). More non-White than NHW patients presented with cerebellar and cranial nerve deficits (i.e., gait ataxia [p = 0.028], nystagmus [p = 0.002], dysconjugate gaze [p = 0.03], hearing loss [p = 0.003], gait instability [p = 0.003], tremor [p = 0.021], or dysmetria [p < 0.001]). Non-White patients had higher rates of skull malformation (p = 0.004), platybasia (p = 0.002), and basilar invagination (p = 0.036). Non-White patients were more likely to be treated at low-volume centers than at high-volume centers (38.7% vs 15.2%; p < 0.01). Non-White patients were older at the time of surgery (p = 0.001) and had longer operative times (p < 0.001), higher estimated blood loss (p < 0.001), and a longer hospital stay (p = 0.04). There were no major group differences in terms of treatments performed or complications. The majority of subjects used private insurance (440, 71.5%), whereas 175 (28.5%) were using Medicaid or self-pay. Private insurance was used in 42.2% of non-White patients compared to 79.8% of NHW patients (p < 0.01). There were no major differences in presentation, treatment, or outcome between insurance groups. In multivariate modeling, non-White patients were more likely to present at an older age after controlling for sex and insurance status (p < 0.01). Non-White and male patients had a longer duration of symptoms before reaching diagnosis (p = 0.033 and 0.004, respectively). CONCLUSIONS Socioeconomic and demographic factors appear to influence the presentation and management of patients with CM-I and SM. Race is associated with age and timing of diagnosis as well as operating room time, estimated blood loss, and length of hospital stay. This exploration of socioeconomic and demographic barriers to care will be useful in understanding how to improve access to pediatric neurosurgical care for patients with CM-I and SM.
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Affiliation(s)
- Syed Hassan A Akbari
- 1Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | | | | | - James Torner
- 4Department of Epidemiology, University of Iowa, Iowa City, Iowa
| | - Douglas L Brockmeyer
- 5Department of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - John C Wellons
- 6Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey R Leonard
- 7Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Francesco T Mangano
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James M Johnston
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Manish N Shah
- 10Department of Pediatric Surgery and Neurosurgery, The University of Texas McGovern Medical School, Houston, Texas
| | - Bermans J Iskandar
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Raheel Ahmed
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gerald F Tuite
- 12Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Bruce A Kaufman
- 13Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David J Daniels
- 14Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Eric M Jackson
- 15Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gerald A Grant
- 16Department of Neurosurgery, Stanford Child Health Research Institute, Stanford, California
| | - Alexander K Powers
- 17Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Daniel E Couture
- 17Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - P David Adelson
- 18Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tord D Alden
- 19Department of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Philipp R Aldana
- 20Department of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Richard C E Anderson
- 21Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nathan R Selden
- 22Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karin Bierbrauer
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William Boydston
- 23Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | - Joshua J Chern
- 23Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | | | - Robert C Dauser
- 24Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Richard G Ellenbogen
- 25Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Jeffrey G Ojemann
- 25Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Herbert E Fuchs
- 26Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Daniel J Guillaume
- 27Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd C Hankinson
- 28Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Brent R O'Neill
- 28Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Mark Iantosca
- 1Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - W Jerry Oakes
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Paul Klimo
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Michael S Muhlbauer
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - J Gordon McComb
- 31Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Arnold H Menezes
- 32Department of Neurosurgery, University of Iowa Hospitals, Iowa City, Iowa
| | - Nickalus R Khan
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Toba N Niazi
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - John Ragheb
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Chevis N Shannon
- 6Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jodi L Smith
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Laurie L Ackerman
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrew H Jea
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Cormac O Maher
- 35Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Prithvi Narayan
- 36Department of Neurological Surgery, St. Christopher's Hospital, Philadelphia, Pennsylvania
| | - Gregory W Albert
- 37Department of Neurosurgery, University of Arkansas College of Medicine, Little Rock, Arkansas
| | - Scellig S D Stone
- 38Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Lissa C Baird
- 38Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Naina L Gross
- 39Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Susan R Durham
- 40Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; and
| | - Stephanie Greene
- 41Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert C McKinstry
- 3Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua S Shimony
- 3Radiology, Washington University School of Medicine, St. Louis, Missouri
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13
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Shah AS, Yahanda AT, Sylvester PT, Evans J, Dunn GP, Jensen RL, Honeycutt J, Cahill DP, Sutherland GR, Oswood M, Shah M, Abram SR, Rich KM, Dowling JL, Leuthardt EC, Dacey RG, Kim AH, Zipfel GJ, Limbrick DD, Smyth MD, Leonard J, Chicoine MR. Using Histopathology to Assess the Reliability of Intraoperative Magnetic Resonance Imaging in Guiding Additional Brain Tumor Resection: A Multicenter Study. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa338_s074] [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: 11/15/2022] Open
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14
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Schaettler MO, Richters MM, Wang AZ, Skidmore ZL, Fisk B, Miller KE, Vickery TL, Kim AH, Chicoine MR, Osbun JW, Leuthardt EC, Dowling JL, Zipfel GJ, Dacey RG, Lu HC, Johanns TM, Griffith OL, Mardis ER, Griffith M, Dunn GP. Characterization of the Genomic and Immunological Diversity of Malignant Brain Tumors Through Multi-Sector Analysis. Cancer Discov 2021; 12:154-171. [PMID: 34610950 DOI: 10.1158/2159-8290.cd-21-0291] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/19/2021] [Accepted: 09/30/2021] [Indexed: 11/16/2022]
Abstract
Despite some success in secondary brain metastases, targeted or immune-based therapies have shown limited efficacy against primary brain malignancies such as glioblastoma (GBM). While the intratumoral heterogeneity of GBM is implicated in treatment resistance, it remains unclear whether this diversity is observed within brain metastases and to what extent cancer-cell intrinsic heterogeneity sculpts the local immune microenvironment. Here, we profiled the immunogenomic state of 93 spatially distinct regions from 30 malignant brain tumors through whole exome, RNA, and TCR-sequencing. Our analyses identified differences between primary and secondary malignancies with gliomas displaying more spatial heterogeneity at the genomic and neoantigen level. Additionally, this spatial diversity was recapitulated in the distribution of T cell clones where some gliomas harbored highly expanded but spatially restricted clonotypes. This study defines the immunogenomic landscape across a cohort of malignant brain tumors and contains implications for the design of targeted and immune-based therapies against intracranial malignancies.
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Affiliation(s)
| | - Megan M Richters
- Department of Medicine, McDonnell Genome Institute, Washington University in St. Louis School of Medicine
| | - Anthony Z Wang
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine
| | - Zachary L Skidmore
- The Genome Institute, Washington University in St. Louis School of Medicine
| | - Bryan Fisk
- McDonnell Genome Institute, Washington University in St. Louis School of Medicine
| | | | - Tammi L Vickery
- Center for Human Immunology and Immunotherapy Programs, Washington University in St. Louis School of Medicine
| | - Albert H Kim
- Neurosurgery, Washington University in St. Louis School of Medicine
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine
| | - Joshua W Osbun
- Neurological Surgery, Washington University in St. Louis
| | - Eric C Leuthardt
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine
| | - Joshua L Dowling
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine
| | - Hsiang-Chih Lu
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine
| | - Tanner M Johanns
- Division of Oncology, Washington University in St. Louis School of Medicine
| | - Obi L Griffith
- McDonnell Genome Institute, Washington University in St. Louis School of Medicine
| | - Elaine R Mardis
- Institute for Genomic Medicine, Nationwide Children's Hospital
| | - Malachi Griffith
- Department of Medicine, McDonnell Genome Institute, Washington University in St. Louis School of Medicine
| | - Gavin P Dunn
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine
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15
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Selden NR, Barbaro NM, Barrow DL, Batjer HH, Branch CL, Burchiel KJ, Byrne RW, Dacey RG, Day AL, Dempsey RJ, Derstine P, Friedman AH, Giannotta SL, Grady MS, Harsh GR, Harbaugh RE, Mapstone TB, Muraszko KM, Origitano TC, Orrico KO, Popp AJ, Sagher O, Selman WR, Zipfel GJ. Neurosurgery residency and fellowship education in the United States: 2 decades of system development by the One Neurosurgery Summit organizations. J Neurosurg 2021; 136:565-574. [PMID: 34359022 DOI: 10.3171/2020.10.jns203125] [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: 08/13/2020] [Accepted: 10/05/2020] [Indexed: 11/06/2022]
Abstract
The purpose of this report is to chronicle a 2-decade period of educational innovation and improvement, as well as governance reform, across the specialty of neurological surgery. Neurological surgery educational and professional governance systems have evolved substantially over the past 2 decades with the goal of improving training outcomes, patient safety, and the quality of US neurosurgical care. Innovations during this period have included the following: creating a consensus national curriculum; standardizing the length and structure of neurosurgical training; introducing educational outcomes milestones and required case minimums; establishing national skills, safety, and professionalism courses; systematically accrediting subspecialty fellowships; expanding professional development for educators; promoting training in research; and coordinating policy and strategy through the cooperation of national stakeholder organizations. A series of education summits held between 2007 and 2009 restructured some aspects of neurosurgical residency training. Since 2010, ongoing meetings of the One Neurosurgery Summit have provided strategic coordination for specialty definition, neurosurgical education, public policy, and governance. The Summit now includes leadership representatives from the Society of Neurological Surgeons, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the American Board of Neurological Surgery, the Review Committee for Neurological Surgery of the Accreditation Council for Graduate Medical Education, the American Academy of Neurological Surgery, and the AANS/CNS Joint Washington Committee. Together, these organizations have increased the effectiveness and efficiency of the specialty of neurosurgery in advancing educational best practices, aligning policymaking, and coordinating strategic planning in order to meet the highest standards of professionalism and promote public health.
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Affiliation(s)
- Nathan R Selden
- 1Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Nicholas M Barbaro
- 2Department of Neurosurgery, University of Texas, Dell Medical School, Austin, Texas
| | - Daniel L Barrow
- 3Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - H Hunt Batjer
- 4Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Charles L Branch
- 5Department of Neurosurgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Kim J Burchiel
- 1Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Richard W Byrne
- 6Department of Neurosurgery, Rush University, Chicago, Illinois
| | - Ralph G Dacey
- 7Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Arthur L Day
- 8Department of Neurosurgery, University of Texas Houston Health Science Center, Houston, Texas
| | - Robert J Dempsey
- 9Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin
| | - Pamela Derstine
- 10Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Allan H Friedman
- 11Department of Neurosurgery, Duke University Health System, Durham, North Carolina
| | - Steven L Giannotta
- 12Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - M Sean Grady
- 13Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Griffith R Harsh
- 14Department of Neurological Surgery, University of California Davis, Sacramento, California
| | - Robert E Harbaugh
- 15Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Timothy B Mapstone
- 16Department of Neurosurgery, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Karin M Muraszko
- 17Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Thomas C Origitano
- 18Neuroscience and Spine Institute, Kalispell Regional Healthcare, Kalispell, Montana
| | | | - A John Popp
- 20Department of Neurosurgery, Albany Medical College and Albany Medical Center Hospital, Albany, New York; and
| | - Oren Sagher
- 17Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Warren R Selman
- 21Department of Neurosurgery, University Hospitals Cleveland and Case Western Reserve University, Cleveland, Ohio
| | - Gregg J Zipfel
- 7Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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16
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Nduom EK, Gephart MH, Chheda MG, Suva ML, Amankulor N, Battiste JD, Campian JL, Dacey RG, Das S, Fecci PE, Hadjipanayis CG, Hoang KB, Jalali A, Orringer D, Patel AJ, Placantonakis D, Rodriguez A, Yang I, Yu JS, Zipfel GJ, Dunn GP, Leuthardt EC, Kim AH. Re-evaluating Biopsy for Recurrent Glioblastoma: A Position Statement by the Christopher Davidson Forum Investigators. Neurosurgery 2021; 89:129-132. [PMID: 33862619 DOI: 10.1093/neuros/nyab063] [Citation(s) in RCA: 3] [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: 12/14/2020] [Accepted: 01/05/2021] [Indexed: 11/15/2022] Open
Abstract
Patients with glioblastoma (GBM) need bold new approaches to their treatment, yet progress has been hindered by a relative inability to dynamically track treatment response, mechanisms of resistance, evolution of targetable mutations, and changes in mutational burden. We are writing on behalf of a multidisciplinary group of academic neuro-oncology professionals who met at the collaborative Christopher Davidson Forum at Washington University in St Louis in the fall of 2019. We propose a dramatic but necessary change to the routine management of patients with GBM to advance the field: to routinely biopsy recurrent GBM at the time of presumed recurrence. Data derived from these samples will identify true recurrence vs treatment effect, avoid treatments with little chance of success, enable clinical trial access, and aid in the scientific advancement of our understanding of GBM.
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Affiliation(s)
- Edjah K Nduom
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Melanie Hayden Gephart
- Department of Neurological Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Milan G Chheda
- Departments of Medicine and Neurology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Mario L Suva
- Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Nduka Amankulor
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James D Battiste
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jian L Campian
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sunit Das
- Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Kimberly B Hoang
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Jalali
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel Orringer
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Akash J Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Analiz Rodriguez
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Isaac Yang
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jennifer S Yu
- Department of Radiation Oncology and Cancer Biology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Greg J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Gavin P Dunn
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Eric C Leuthardt
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Albert H Kim
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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17
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Huguenard AL, Gupta VP, Braverman AC, Dacey RG. Genetic and heritable considerations in patients or families with both intracranial and extracranial aneurysms. J Neurosurg 2021; 134:1999-2006. [PMID: 33386011 DOI: 10.3171/2020.8.jns203234] [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: 11/06/2022]
Affiliation(s)
- Anna L Huguenard
- 1Department of Neurosurgery, Washington University in St. Louis; and
| | - Vivek P Gupta
- 1Department of Neurosurgery, Washington University in St. Louis; and
| | - Alan C Braverman
- 2Cardiovascular Division, Department of Medicine, Washington University in St. Louis, Missouri
| | - Ralph G Dacey
- 1Department of Neurosurgery, Washington University in St. Louis; and
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18
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Shah AS, Yahanda AT, Sylvester PT, Evans J, Dunn GP, Jensen RL, Honeycutt J, Cahill DP, Sutherland GR, Oswood M, Shah M, Abram SR, Rich KM, Dowling JL, Leuthardt EC, Dacey RG, Kim AH, Zipfel GJ, Limbrick DD, Smyth MD, Leonard J, Chicoine MR. Using Histopathology to Assess the Reliability of Intraoperative Magnetic Resonance Imaging in Guiding Additional Brain Tumor Resection: A Multicenter Study. Neurosurgery 2020; 88:E49-E59. [PMID: 32803226 DOI: 10.1093/neuros/nyaa338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/31/2019] [Accepted: 05/24/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Intraoperative magnetic resonance imaging (iMRI) is a powerful tool for guiding brain tumor resections, provided that it accurately discerns residual tumor. OBJECTIVE To use histopathology to assess how reliably iMRI may discern additional tumor for a variety of tumor types, independent of the indications for iMRI. METHODS A multicenter database was used to calculate the odds of additional resection during the same surgical session for grade I to IV gliomas and pituitary adenomas. The reliability of iMRI for identifying residual tumor was assessed using histopathology of tissue resected after iMRI. RESULTS Gliomas (904/1517 cases, 59.6%) were more likely than pituitary adenomas (176/515, 34.2%) to receive additional resection after iMRI (P < .001), but these tumors were equally likely to have additional tissue sent for histopathology (398/904, 44.4% vs 66/176, 37.5%; P = .11). Tissue samples were available for resections after iMRI for 464 cases, with 415 (89.4%) positive for tumor. Additional resections after iMRI for gliomas (361/398, 90.7%) were more likely to yield additional tumor compared to pituitary adenomas (54/66, 81.8%) (P = .03). There were no significant differences in resection after iMRI yielding histopathologically positive tumor between grade I (58/65 cases, 89.2%; referent), grade II (82/92, 89.1%) (P = .98), grade III (72/81, 88.9%) (P = .95), or grade IV gliomas (149/160, 93.1%) (P = .33). Additional resection for previously resected tumors (122/135 cases, 90.4%) was equally likely to yield histopathologically confirmed tumor compared to newly-diagnosed tumors (293/329, 89.0%) (P = .83). CONCLUSION Histopathological analysis of tissue resected after use of iMRI for grade I to IV gliomas and pituitary adenomas demonstrates that iMRI is highly reliable for identifying residual tumor.
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Affiliation(s)
- Amar S Shah
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - John Evans
- Washington University School of Medicine, St. Louis, Missouri
| | - Gavin P Dunn
- Washington University School of Medicine, St. Louis, Missouri
| | - Randy L Jensen
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | | | | | - Mark Oswood
- University of Minnesota, Minneapolis, Minnesota.,Allina Health, Minneapolis, Minnesota
| | - Mitesh Shah
- Goodman Campbell and Indiana University, Indianapolis, Indiana
| | | | - Keith M Rich
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Ralph G Dacey
- Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Matthew D Smyth
- Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey Leonard
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
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Yahanda AT, Shah AS, Sylvester P, Evans J, Dunn GP, Jensen RL, Honeycutt JH, Cahill DP, Sutherland GR, Oswood MC, Shah MV, Abram SR, Rich KM, Dowling JL, Leuthardt EC, Dacey RG, Kim AH, Zipfel GJ, Limbrick DD, Smyth MD, Leonard JR, Chicoine MR. Using Histopathology to Assess the Reliability With Which Intraoperative MRI Identifies Residual Brain Tumor. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_914] [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: 11/14/2022] Open
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20
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Chicoine MR, Yahanda AT, Dacey RG. A tribute to the late Professor Donald Simpson, Australian neurosurgeon and namesake of the Simpson grading system for meningioma extent of resection. J Neurosurg 2020; 135:644-650. [PMID: 33096526 DOI: 10.3171/2020.6.jns201331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/09/2020] [Indexed: 11/06/2022]
Abstract
Donald Simpson (1927-2018) was a neurosurgeon from Adelaide, Australia, who is often cited for the 1957 publication he wrote as a trainee on the relationship between extent of resection and outcomes for meningiomas. That paper summarized a series of over 300 patients operated on in England by well-known neurosurgeons Sir Hugh Cairns and Joseph Buford Pennybacker. Simpson was also known later in his career, when he was at the University of Adelaide in South Australia, for his contributions to the areas of hydrocephalus, spina bifida, craniofacial anomalies, head injury, brain abscesses, and neurosurgical history, and he published extensively on these topics. In addition to his work in clinical neurosurgery, Simpson made humanitarian contributions studying kuru in New Guinea and aiding refugees during the Vietnam War. Simpson was an active member and leader of many Australian surgical organizations and was an officer of the Order of Australia. Donald Simpson's legacy as an adult and pediatric neurosurgeon, an academician, a leader, and a humanitarian is extensive and will prove long lasting. Professor Simpson's life serves as an example from which all neurosurgeons may learn.
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21
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Shah AS, Sylvester PT, Yahanda AT, Vellimana AK, Dunn GP, Evans J, Rich KM, Dowling JL, Leuthardt EC, Dacey RG, Kim AH, Grubb RL, Zipfel GJ, Oswood M, Jensen RL, Sutherland GR, Cahill DP, Abram SR, Honeycutt J, Shah M, Tao Y, Chicoine MR. Intraoperative MRI for newly diagnosed supratentorial glioblastoma: a multicenter-registry comparative study to conventional surgery. J Neurosurg 2020; 135:505-514. [PMID: 33035996 DOI: 10.3171/2020.6.jns19287] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 02/01/2019] [Accepted: 06/04/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative MRI (iMRI) is used in the surgical treatment of glioblastoma, with uncertain effects on outcomes. The authors evaluated the impact of iMRI on extent of resection (EOR) and overall survival (OS) while controlling for other known and suspected predictors. METHODS A multicenter retrospective cohort of 640 adult patients with newly diagnosed supratentorial glioblastoma who underwent resection was evaluated. iMRI was performed in 332/640 cases (51.9%). Reviews of MRI features and tumor volumetric analysis were performed on a subsample of cases (n = 286; 110 non-iMRI, 176 iMRI) from a single institution. RESULTS The median age was 60.0 years (mean 58.5 years, range 20.5-86.3 years). The median OS was 17.0 months (95% CI 15.6-18.4 months). Gross-total resection (GTR) was achieved in 403/640 cases (63.0%). Kaplan-Meier analysis of 286 cases with volumetric analysis for EOR (grouped into 100%, 95%-99%, 80%-94%, and 50%-79%) showed longer OS for 100% EOR compared to all other groups (p < 0.01). Additional resection after iMRI was performed in 104/122 cases (85.2%) with initial subtotal resection (STR), leading to a 6.3% mean increase in EOR and a 2.2-cm3 mean decrease in tumor volume. For iMRI cases with volumetric analysis, the GTR rate increased from 54/176 (30.7%) on iMRI to 126/176 (71.5%) postoperatively. The EOR was significantly higher in the iMRI group for intended GTR and STR groups (p = 0.02 and p < 0.01, respectively). Predictors of GTR on multivariate logistic regression included iMRI use and intended GTR. Predictors of shorter OS on multivariate Cox regression included older age, STR, isocitrate dehydrogenase 1 (IDH1) wild type, no O 6-methylguanine DNA methyltransferase (MGMT) methylation, and no Stupp therapy. iMRI was a significant predictor of OS on univariate (HR 0.82, 95% CI 0.69-0.98; p = 0.03) but not multivariate analyses. Use of iMRI was not associated with an increased rate of new permanent neurological deficits. CONCLUSIONS GTR increased OS for patients with newly diagnosed glioblastoma after adjusting for other prognostic factors. iMRI increased EOR and GTR rate and was a significant predictor of GTR on multivariate analysis; however, iMRI was not an independent predictor of OS. Additional supporting evidence is needed to determine the clinical benefit of iMRI in the management of glioblastoma.
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Affiliation(s)
- Amar S Shah
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Peter T Sylvester
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander T Yahanda
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ananth K Vellimana
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gavin P Dunn
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - John Evans
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua L Dowling
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Eric C Leuthardt
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Robert L Grubb
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J Zipfel
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mark Oswood
- 2Department of Radiology, University of Minnesota, Minneapolis, Minnesota
- 3Allina Health, Minneapolis, Minnesota
| | - Randy L Jensen
- 4Department of Neurosurgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Garnette R Sutherland
- 5Department of Clinical Sciences and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Daniel P Cahill
- 6Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven R Abram
- 7Department of Neurosurgery, St. Thomas Hospital, Nashville, Tennessee
| | - John Honeycutt
- 8Department of Neurosurgery, Cook Children's Hospital, Fort Worth, Texas; and
| | - Mitesh Shah
- 9Department of Neurological Surgery, Goodman Campbell and Indiana University, Indianapolis, Indiana
| | - Yu Tao
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R Chicoine
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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22
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Hwang JY, Aum DJ, Chicoine MR, Dacey RG, Osbun JW, Rich KM, Zipfel GJ, Klatt-Cromwell CN, McJunkin JL, Pipkorn P, Schneider JS, Silverstein JM, Kim AH. Axis-specific analysis and predictors of endocrine recovery and deficits for non-functioning pituitary adenomas undergoing endoscopic transsphenoidal surgery. Pituitary 2020; 23:389-399. [PMID: 32388803 DOI: 10.1007/s11102-020-01045-z] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE Endoscopic transsphenoidal surgery (ETSS) is a well-established treatment for patients with nonfunctioning pituitary adenomas (NFPAs). Data on the rates of pituitary dysfunction and recovery in a large cohort of NFPA patients undergoing ETSS and the predictors of endocrine function before and after ETSS are scarce. This study is purposed to analyze the comprehensive changes in hormonal function and identify factors that predict recovery or worsening of hormonal axes following ETSS for NFPA. METHODS A retrospective review of 601 consecutive patients who underwent ETSS between 2010 and 2018 at one institution was performed. Recovery or development of new hypopituitarism was analyzed in 209 NFPA patients who underwent ETSS. RESULTS Patients with preoperative endocrine deficits (59.8%) in one or more pituitary axes had larger tumor volumes (P = 0.001) than those without preoperative deficits. Recovery of preoperative pituitary deficit occurred in all four axes, with overall mean recovery of 29.7%. The cortisol axis showed the highest recovery whereas the thyroid axis showed the lowest, with 1-year cumulative recovery rates of 44.3% and 6.1%, respectively. Postoperative hypopituitarism occurred overall in 17.2%, most frequently in the thyroid axis (24.3%, 27/111) and least frequently in the cortisol axis (9.7%, 16/165). Axis-specific predictors of post-operative recovery and deficiency were identified. CONCLUSIONS Dynamic alterations in pituitary hormones were observed in a proportion of patients following ETSS in NFPA patients. Postoperative endocrine vulnerability, recovery, and factors that predicted recovery or loss of endocrine function depended on the hormonal system, necessitating an axis-specific surveillance strategy postoperatively.
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Affiliation(s)
- Jenie Y Hwang
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Diane J Aum
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Joshua W Osbun
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Cristine N Klatt-Cromwell
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jonathan L McJunkin
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - John S Schneider
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie M Silverstein
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Albert H Kim
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
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23
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Yahanda AT, Patel B, Shah AS, Cahill DP, Sutherland G, Honeycutt J, Jensen RL, Rich KM, Dowling JL, Limbrick DD, Dacey RG, Kim AH, Leuthardt EC, Dunn GP, Zipfel GJ, Leonard JR, Smyth MD, Shah MV, Abram SR, Evans J, Chicoine MR. Impact of Intraoperative Magnetic Resonance Imaging and Other Factors on Surgical Outcomes for Newly Diagnosed Grade II Astrocytomas and Oligodendrogliomas: A Multicenter Study. Neurosurgery 2020; 88:63-73. [DOI: 10.1093/neuros/nyaa320] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/24/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Few studies use large, multi-institutional patient cohorts to examine the role of intraoperative magnetic resonance imaging (iMRI) in the resection of grade II gliomas.
OBJECTIVE
To assess the impact of iMRI and other factors on overall survival (OS) and progression-free survival (PFS) for newly diagnosed grade II astrocytomas and oligodendrogliomas.
METHODS
Retrospective analyses of a multicenter database assessed the impact of patient-, treatment-, and tumor-related factors on OS and PFS.
RESULTS
A total of 232 resections (112 astrocytomas and 120 oligodendrogliomas) were analyzed. Oligodendrogliomas had longer OS (P < .001) and PFS (P = .01) than astrocytomas. Multivariate analyses demonstrated improved OS for gross total resection (GTR) vs subtotal resection (STR; P = .006, hazard ratio [HR]: .23) and near total resection (NTR; P = .02, HR: .64). GTR vs STR (P = .02, HR: .54), GTR vs NTR (P = .04, HR: .49), and iMRI use (P = .02, HR: .54) were associated with longer PFS. Frontal (P = .048, HR: 2.11) and occipital/parietal (P = .003, HR: 3.59) locations were associated with shorter PFS (vs temporal). Kaplan-Meier analyses showed longer OS with increasing extent of surgical resection (EOR) (P = .03) and 1p/19q gene deletions (P = .02). PFS improved with increasing EOR (P = .01), GTR vs NTR (P = .02), and resections above STR (P = .04). Factors influencing adjuvant treatment (35.3% of patients) included age (P = .002, odds ratio [OR]: 1.04) and EOR (P = .003, OR: .39) but not glioma subtype or location. Additional tumor resection after iMRI was performed in 105/159 (66%) iMRI cases, yielding GTR in 54.5% of these instances.
CONCLUSION
EOR is a major determinant of OS and PFS for patients with grade II astrocytomas and oligodendrogliomas. Intraoperative MRI may improve EOR and was associated with increased PFS.
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Affiliation(s)
- Alexander T Yahanda
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Bhuvic Patel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Amar S Shah
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel P Cahill
- Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Garnette Sutherland
- Department of Neurological Surgery, University of Calgary School of Medicine, Calgary, Canada
| | - John Honeycutt
- Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas
| | - Randy L Jensen
- Department of Neurological Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Joshua L Dowling
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - David D Limbrick
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gavin P Dunn
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Jeffrey R Leonard
- Department of Neurological Surgery, Ohio State University College of Medicine, Columbus, Ohio
| | - Matthew D Smyth
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Mitesh V Shah
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Steven R Abram
- Department of Neurological Surgery, St. Thomas Hospital, Nashville, Tennessee
| | - John Evans
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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24
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Strahle JM, Taiwo R, Averill C, Torner J, Gewirtz JI, Shannon CN, Bonfield CM, Tuite GF, Bethel-Anderson T, Anderson RCE, Kelly MP, Shimony JS, Dacey RG, Smyth MD, Park TS, Limbrick DD. Radiological and clinical associations with scoliosis outcomes after posterior fossa decompression in patients with Chiari malformation and syrinx from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2020; 26:53-59. [PMID: 32276246 DOI: 10.3171/2020.1.peds18755] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 06/30/2019] [Accepted: 01/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In patients with Chiari malformation type I (CM-I) and a syrinx who also have scoliosis, clinical and radiological predictors of curve regression after posterior fossa decompression are not well known. Prior reports indicate that age younger than 10 years and a curve magnitude < 35° are favorable predictors of curve regression following surgery. The aim of this study was to determine baseline radiological factors, including craniocervical junction alignment, that might predict curve stability or improvement after posterior fossa decompression. METHODS A large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and a syrinx (≥ 3 mm in width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°) in patients who underwent posterior fossa decompression and who also had follow-up imaging. RESULTS Of 825 patients with CM-I and a syrinx, 251 (30.4%) were noted to have scoliosis present at the time of diagnosis. Forty-one (16.3%) of these patients underwent posterior fossa decompression and had follow-up imaging to assess for scoliosis. Twenty-three patients (56%) were female, the mean age at time of CM-I decompression was 10.0 years, and the mean follow-up duration was 1.3 years. Nine patients (22%) had stable curves, 16 (39%) showed improvement (> 5°), and 16 (39%) displayed curve progression (> 5°) during the follow-up period. Younger age at the time of decompression was associated with improvement in curve magnitude; for those with curves of ≤ 35°, 17% of patients younger than 10 years of age had curve progression compared with 64% of those 10 years of age or older (p = 0.008). There was no difference by age for those with curves > 35°. Tonsil position, baseline syrinx dimensions, and change in syrinx size were not associated with the change in curve magnitude. There was no difference in progression after surgery in patients who were also treated with a brace compared to those who were not treated with a brace for scoliosis. CONCLUSIONS In this cohort of patients with CM-I, a syrinx, and scoliosis, younger age at the time of decompression was associated with improvement in curve magnitude following surgery, especially in patients younger than 10 years of age with curves of ≤ 35°. Baseline tonsil position, syrinx dimensions, frontooccipital horn ratio, and craniocervical junction morphology were not associated with changes in curve magnitude after surgery.
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Affiliation(s)
- Jennifer M Strahle
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Rukayat Taiwo
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christine Averill
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - James Torner
- 2Department of Epidemiology, University of Iowa, Iowa City, Iowa
| | - Jordan I Gewirtz
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Chevis N Shannon
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gerald F Tuite
- 4Department of Neurosurgery, Neuroscience Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Tammy Bethel-Anderson
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Richard C E Anderson
- 6Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York; and
| | - Michael P Kelly
- 7Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua S Shimony
- 5Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Smyth
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Tae Sung Park
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - David D Limbrick
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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Osbun JW, Dacey RG, Barrow DL, Saindane AM, Nimsky C. Introduction Imaging in neurosurgical disease. Neurosurg Focus 2019; 47:E1. [PMID: 31786553 DOI: 10.3171/2019.9.focus19764] [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: 11/06/2022]
Affiliation(s)
- Joshua W Osbun
- 1Departments of Neurosurgery, Radiology, and Neurology, Washington University in St. Louis
| | - Ralph G Dacey
- 2Department of Neurosurgery, Washington University in St. Louis, Missouri
| | | | - Amit M Saindane
- 4Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia; and
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26
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Strahle JM, Taiwo R, Averill C, Torner J, Shannon CN, Bonfield CM, Tuite GF, Bethel-Anderson T, Rutlin J, Brockmeyer DL, Wellons JC, Leonard JR, Mangano FT, Johnston JM, Shah MN, Iskandar BJ, Tyler-Kabara EC, Daniels DJ, Jackson EM, Grant GA, Couture DE, Adelson PD, Alden TD, Aldana PR, Anderson RCE, Selden NR, Baird LC, Bierbrauer K, Chern JJ, Whitehead WE, Ellenbogen RG, Fuchs HE, Guillaume DJ, Hankinson TC, Iantosca MR, Oakes WJ, Keating RF, Khan NR, Muhlbauer MS, McComb JG, Menezes AH, Ragheb J, Smith JL, Maher CO, Greene S, Kelly M, O'Neill BR, Krieger MD, Tamber M, Durham SR, Olavarria G, Stone SSD, Kaufman BA, Heuer GG, Bauer DF, Albert G, Greenfield JP, Wait SD, Van Poppel MD, Eskandari R, Mapstone T, Shimony JS, Dacey RG, Smyth MD, Park TS, Limbrick DD. Radiological and clinical predictors of scoliosis in patients with Chiari malformation type I and spinal cord syrinx from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2019; 24:520-527. [PMID: 31419800 DOI: 10.3171/2019.5.peds18527] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 11/02/2018] [Accepted: 05/09/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Scoliosis is frequently a presenting sign of Chiari malformation type I (CM-I) with syrinx. The authors' goal was to define scoliosis in this population and describe how radiological characteristics of CM-I and syrinx relate to the presence and severity of scoliosis. METHODS A large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°). RESULTS Based on available imaging of patients with CM-I and syrinx, 260 of 825 patients (31%) had a clear diagnosis of scoliosis based on radiographs or coronal MRI. Forty-nine patients (5.9%) did not have scoliosis, and in 516 (63%) patients, a clear determination of the presence or absence of scoliosis could not be made. Comparison of patients with and those without a definite scoliosis diagnosis indicated that scoliosis was associated with wider syrinxes (8.7 vs 6.3 mm, OR 1.25, p < 0.001), longer syrinxes (10.3 vs 6.2 levels, OR 1.18, p < 0.001), syrinxes with their rostral extent located in the cervical spine (94% vs 80%, OR 3.91, p = 0.001), and holocord syrinxes (50% vs 16%, OR 5.61, p < 0.001). Multivariable regression analysis revealed syrinx length and the presence of holocord syrinx to be independent predictors of scoliosis in this patient cohort. Scoliosis was not associated with sex, age at CM-I diagnosis, tonsil position, pB-C2 distance (measured perpendicular distance from the ventral dura to a line drawn from the basion to the posterior-inferior aspect of C2), clivoaxial angle, or frontal-occipital horn ratio. Average curve magnitude was 29.9°, and 37.7% of patients had a left thoracic curve. Older age at CM-I or syrinx diagnosis (p < 0.0001) was associated with greater curve magnitude whereas there was no association between syrinx dimensions and curve magnitude. CONCLUSIONS Syrinx characteristics, but not tonsil position, were related to the presence of scoliosis in patients with CM-I, and there was an independent association of syrinx length and holocord syrinx with scoliosis. Further study is needed to evaluate the nature of the relationship between syrinx and scoliosis in patients with CM-I.
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Affiliation(s)
- Jennifer M Strahle
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Rukayat Taiwo
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christine Averill
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - James Torner
- 2Department of Epidemiology, University of Iowa, Iowa City, Iowa
| | - Chevis N Shannon
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gerald F Tuite
- 4Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Tammy Bethel-Anderson
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jerrel Rutlin
- 5Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Douglas L Brockmeyer
- 6Department of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - John C Wellons
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey R Leonard
- 7Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Francesco T Mangano
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James M Johnston
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Manish N Shah
- 10Department of Pediatric Surgery and Neurosurgery, The University of Texas McGovern Medical School, Houston, Texas
| | - Bermans J Iskandar
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Elizabeth C Tyler-Kabara
- 12Department of Neurosurgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - David J Daniels
- 13Department of Neurosurgery, The Mayo Clinic, Rochester, Minnesota
| | - Eric M Jackson
- 14Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gerald A Grant
- 15Department of Neurosurgery, Stanford Child Health Research Institute, Stanford, California
| | - Daniel E Couture
- 16Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - P David Adelson
- 17Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tord D Alden
- 18Department of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Philipp R Aldana
- 19Department of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Richard C E Anderson
- 20Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nathan R Selden
- 21Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Lissa C Baird
- 21Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karin Bierbrauer
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joshua J Chern
- 22Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | | | - Richard G Ellenbogen
- 24Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Herbert E Fuchs
- 25Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Daniel J Guillaume
- 26Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd C Hankinson
- 27Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Mark R Iantosca
- 28Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - W Jerry Oakes
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nickalus R Khan
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Michael S Muhlbauer
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - J Gordon McComb
- 31Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Arnold H Menezes
- 32Department of Neurosurgery, University of Iowa Hospitals, Iowa City, Iowa
| | - John Ragheb
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Jodi L Smith
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Cormac O Maher
- 35Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Stephanie Greene
- 12Department of Neurosurgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Michael Kelly
- 36Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Brent R O'Neill
- 27Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Mark D Krieger
- 31Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Mandeep Tamber
- 37Department of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Susan R Durham
- 38Department of Neurosurgery, University of Vermont College of Medicine, Burlington, Vermont
| | | | - Scellig S D Stone
- 40Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Bruce A Kaufman
- 41Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gregory G Heuer
- 42Division of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - David F Bauer
- 43Department of Neurosurgery, Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Gregory Albert
- 44Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey P Greenfield
- 45Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Scott D Wait
- 46Department of Neurological Surgery, Levine Children's Hospital, Charlotte, North Carolina
| | - Mark D Van Poppel
- 46Department of Neurological Surgery, Levine Children's Hospital, Charlotte, North Carolina
| | - Ramin Eskandari
- 47Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina; and
| | - Timothy Mapstone
- 48Department of Neurosurgery, Oklahoma University Medical Center, Oklahoma City, Oklahoma
| | - Joshua S Shimony
- 5Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Smyth
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Tae Sung Park
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - David D Limbrick
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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Johanns TM, Miller CA, Liu CJ, Perrin RJ, Bender D, Kobayashi DK, Campian JL, Chicoine MR, Dacey RG, Huang J, Fritsch EF, Gillanders WE, Artyomov MN, Mardis ER, Schreiber RD, Dunn GP. Detection of neoantigen-specific T cells following a personalized vaccine in a patient with glioblastoma. Oncoimmunology 2019; 8:e1561106. [PMID: 30906654 PMCID: PMC6422384 DOI: 10.1080/2162402x.2018.1561106] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [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: 10/08/2018] [Revised: 11/27/2018] [Accepted: 12/10/2018] [Indexed: 12/30/2022] Open
Abstract
Neoantigens represent promising targets for personalized cancer vaccine strategies. However, the feasibility of this approach in lower mutational burden tumors like glioblastoma (GBM) remains unknown. We have previously reported the use of an immunogenomics pipeline to identify candidate neoantigens in preclinical models of GBM. Here, we report the application of the same immunogenomics pipeline to identify candidate neoantigens and guide screening for neoantigen-specific T cell responses in a patient with GBM treated with a personalized synthetic long peptide vaccine following autologous tumor lysate DC vaccination. Following vaccination, reactivity to three HLA class I- and five HLA class II-restricted candidate neoantigens were detected by IFN-γ ELISPOT in peripheral blood. A similar pattern of reactivity was observed among isolated post-treatment tumor-infiltrating lymphocytes. Genomic analysis of pre- and post-treatment GBM reflected clonal remodeling. These data demonstrate the feasibility and translational potential of a therapeutic neoantigen-based vaccine approach in patients with primary CNS tumors.
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Affiliation(s)
- Tanner M Johanns
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, USA.,Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
| | - Christopher A Miller
- The McDonnell Genome Institute, Washington University in St. Louis, St. Louis, MO, USA
| | - Connor J Liu
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard J Perrin
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Diane Bender
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
| | - Dale K Kobayashi
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
| | - Jian L Campian
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, USA
| | | | - William E Gillanders
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA.,Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Maxim N Artyomov
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Elaine R Mardis
- Institute for Genomic Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Robert D Schreiber
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gavin P Dunn
- Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Dacey RG, Flouty OE, Grady MS, Howard MA, Mayberg MR. Shunt scissors: technical note. J Neurosurg 2018; 129:1200-1202. [PMID: 29219754 DOI: 10.3171/2017.6.jns171108] [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: 05/03/2017] [Accepted: 06/19/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEWhen performing ventriculoperitoneal shunt surgery it is necessary to create a subgaleal pocket that is of sufficient size to accommodate a shunt valve. In most cases the valve is placed over the posterior skull where the galea begins to transition to suboccipital neck fascia. Dense fibrous attachments in this region of the skull make it technically awkward to develop the subgaleal valve pocket using standard scissors and a blunt dissection technique. In this report the authors describe a new device that enables surgeons to create the shunt valve pocket by using a simple semi-sharp dissection technique.METHODSThe authors analyzed the deficiencies of the standard valve pocket dissection technique and designed shunt scissors that address the identified shortcomings. These new scissors allow the surgeon to sharply dissect the subgaleal space by using an efficient hand-closing maneuver.RESULTSStandard surgical scissors were modified to create shunt scissors that were tested on the benchtop and used in the operating room. In all cases the shunt scissors proved easy to use and allowed the efficient and reliable creation of a subgaleal valve pocket in a technically pleasing manner.CONCLUSIONSShunt scissors represent an incremental technical advance in the field of neurosurgical shunt operations.
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Affiliation(s)
- Ralph G Dacey
- 1Department of Neurosurgery, Washington University, St. Louis, Missouri
| | - Oliver E Flouty
- 2Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - M Sean Grady
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Matthew A Howard
- 2Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Marc R Mayberg
- 4Department of Neurosurgery, University of Washington, Seattle, Washington
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Lee JJ, Shimony JS, Jafri H, Zazulia AR, Dacey RG, Zipfel GR, Derdeyn CP. Hemodynamic Impairment Measured by Positron-Emission Tomography Is Regionally Associated with Decreased Cortical Thickness in Moyamoya Phenomenon. AJNR Am J Neuroradiol 2018; 39:2037-2044. [PMID: 30361434 DOI: 10.3174/ajnr.a5812] [Citation(s) in RCA: 6] [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: 02/12/2018] [Accepted: 08/06/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Impaired cerebrovascular reactivity has been associated with decreased cortical thickness in patients with arterial occlusive diseases. This study tests the hypothesis that severe hemodynamic impairment, indicated by increased oxygen extraction fraction ratios on positron-emission tomography with 15O tracers, is associated with decreased cortical thickness in patients with Moyamoya phenomenon. MATERIALS AND METHODS Patients with unilateral or bilateral idiopathic Moyamoya phenomenon were recruited. Oxygen extraction fraction ratio maps were generated from cerebral images of O[15O] counts divided by H2[15O] counts with normalization by corresponding cerebellar counts. The normal range of the oxygen extraction fraction ratio was estimated from historically available healthy control subjects. Cortical thickness was estimated from T1-weighted MR imaging and FreeSurfer. Regional samples of oxygen extraction fraction ratios and cortical thicknesses were drawn using FreeSurfer parcellations, retaining only parcellations from the vascular territory of the middle cerebral artery. RESULTS Complete MR imaging and PET datasets were available in 35 subjects, including 23 women; the mean age at scanning was 44 years. Patients with Moyamoya phenomenon had a significantly increased regional oxygen extraction fraction ratio compared with 15 healthy control subjects (P < .001). Regional oxygen extraction fraction ratio and age were significant predictors of cortical thickness (P < .001 for each) in a generalized linear mixed-effects model. Using hemisphere averages and patient averages, we found that only age was a significant predictor of cortical thickness (P < .001). CONCLUSIONS Chronic hemodynamic impairment, as indicated by a higher regional oxygen extraction fraction ratio, was significantly predictive of reduced cortical thickness in mixed-effects analysis of FreeSurfer regions. This phenomenon may be related to reversible metabolic down-regulation.
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Affiliation(s)
- J J Lee
- From the Mallinckrodt Institute of Radiology (J.J.L., J.S.S., H.J., A.R.Z.)
| | - J S Shimony
- From the Mallinckrodt Institute of Radiology (J.J.L., J.S.S., H.J., A.R.Z.)
| | - H Jafri
- From the Mallinckrodt Institute of Radiology (J.J.L., J.S.S., H.J., A.R.Z.)
| | - A R Zazulia
- From the Mallinckrodt Institute of Radiology (J.J.L., J.S.S., H.J., A.R.Z.).,Departments of Neurology (A.R.Z., G.R.Z.)
| | - R G Dacey
- Neurosurgery (R.G.D., G.R.Z.), Washington University, St Louis, Missouri
| | - G R Zipfel
- Departments of Neurology (A.R.Z., G.R.Z.).,Neurosurgery (R.G.D., G.R.Z.), Washington University, St Louis, Missouri
| | - C P Derdeyn
- Department of Radiology (C.P.D.), University of Iowa, Iowa City, Iowa
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Sterl K, Thompson B, Goss CW, Dacey RG, Rich KM, Zipfel GJ, Chicoine MR, Kim AH, Silverstein JM. Withholding Perioperative Steroids in Patients Undergoing Transsphenoidal Resection for Pituitary Disease: Randomized Prospective Clinical Trial to Assess Safety. Neurosurgery 2018; 85:E226-E232. [DOI: 10.1093/neuros/nyy479] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/18/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Perioperative steroid protocols for patients undergoing transsphenoidal surgery (TSS) for pituitary pathology vary by institution.
OBJECTIVE
To assess the safety of withholding glucocorticoids in patients undergoing TSS.
METHODS
Patients with an intact hypothalamic-pituitary-adrenal (HPA) axis undergoing TSS for a pituitary tumor at the same academic institution between 2012 and 2015 were randomized to either receive 100 mg of intravenous hydrocortisone followed by 0.5 mg of intravenous dexamethasone every 6 h for 4 doses (STER, n = 23) or to undergo surgery without steroids (NOSTER, n = 20). Postoperative cortisol levels were then used to determine the need for glucocorticoids after surgery. Data regarding postoperative cortisol levels, hospital stay length, and complications were collected.
RESULTS
Mean postoperative 8 am cortisol levels were higher in the NOSTER group compared to the STER group (745 ± 359 nmol/L and 386 ± 193 nmol/L, respectively, P = .001) and more patients were discharged on glucocorticoids in the STER group (42% vs 12%, P = .07). There was no difference in the incidence of postoperative complications, including hyperglycemia, diabetes insipidus, or permanent adrenal insufficiency. Permanent adrenal insufficiency occurred in 8% of patients.
CONCLUSION
Perioperative steroids can be safely withheld in patients with an intact HPA axis undergoing TSS. Although administration of perioperative glucocorticoids does not appear to increase the risk of complications, it may interfere with assessment of the HPA axis after surgery.
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Affiliation(s)
- Karin Sterl
- Divsion of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| | - Bithika Thompson
- Division of Endocrinology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Julie M Silverstein
- Divsion of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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Shah AS, Sylvester P, Vellimana AK, Dunn GP, Evans J, Jensen RL, Honeycutt JH, Sutherland GR, Cahill DP, Shah MV, Abram SR, Oswood MC, Kim AH, Leuthardt EC, Dowling JL, Rich KM, Dacey RG, Zipfel GJ, Tao Y, Chicoine MR. 215 The Impact of Intraoperative MRI and Other Factors on Survival for Patients With Newly Diagnosed Glioblastoma. A Multicenter Assessment of Over 800 Patients. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.215] [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: 11/13/2022] Open
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Yasin JT, Wallace AN, Madaelil TP, Osbun JW, Moran CJ, Cross DT, Limbrick DD, Zipfel GJ, Dacey RG, Kansagra AP. Treatment of pediatric intracranial aneurysms: case series and meta-analysis. J Neurointerv Surg 2018; 11:257-264. [DOI: 10.1136/neurintsurg-2018-014001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/13/2018] [Accepted: 07/21/2018] [Indexed: 11/04/2022]
Abstract
BackgroundThere are limited outcome data to guide the choice of treatment in pediatric patients with cerebral aneurysms.ObjectiveTo describe our institutional experience treating pediatric patients with cerebral aneurysms and to conduct a meta-analysis of available studies to provide the best current evidence on treatment related outcomes.MethodsWe identified pediatric patients with cerebral aneurysms evaluated or treated at our institution using a comprehensive case log. We also identified studies to include in a meta-analysis through a systematic search of Pubmed, SCOPUS, EMBASE, and the Cochrane Database of Systematic Reviews. As part of both the local analysis and meta-analysis, we recorded patient characteristics, aneurysm characteristics, management, and outcomes. Statistical analysis was performed using Fisher’s exact test and the two tailed Student’s t test, as appropriate.Results42 pediatric patients with 57 aneurysms were evaluated at our institution, and treatment specific outcome data were available in 560 patients as part of our meta-analysis. Endovascular and surgical treatments yielded comparable rates of favorable outcome in all children (88.3% vs 82.7%, respectively, P=0.097), in children with ruptured aneurysms (75% vs 83%, respectively, P=0.357), and in children with unruptured aneurysms (96% vs 97%, respectively, P=1.000).ConclusionEndovascular and surgical treatment yield comparable long term clinical outcomes in pediatric patients with cerebral aneurysms.
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Raman HS, Limbrick DD, Ray WZ, Coble DW, Church S, Dacey RG, Zipfel GJ. Prevalence, management, and outcome of problem residents among neurosurgical training programs in the United States. J Neurosurg 2018; 130:322-326. [DOI: 10.3171/2017.8.jns171719] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/28/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe challenging nature of neurosurgical residency necessitates that appropriate measures are taken by training programs to ensure that residents are properly progressing through their education. Residents who display a pattern of performance deficiencies must be identified and promptly addressed by faculty and program directors to ensure that resident training and patient care are not affected. While studies have been conducted to characterize these so-called “problem residents” in other specialties, no current data regarding the prevalence and management of such residents in neurosurgery exist. The purpose of this study was to determine the rate and the outcome of problem residents in US neurosurgical residency programs and identify predictive risk factors that portend a resident’s departure from the program.METHODSAn anonymous nationwide survey was sent to all 108 neurosurgical training programs in the US to assess a 20-year history of overall attrition as well as the management course of problem residents, including the specific deficiencies of the resident, management strategies used by faculty, and the eventual outcome of each resident’s training.RESULTSResponses were received from 36 centers covering a total of 1573 residents, with the programs providing a mean 17.4 years’ worth of data (95% CI 15.3–19.4 years). The mean prevalence of problem residents among training programs was 18.1% (95% CI 14.7%–21.6%). The most common deficiencies recognized by program directors were poor communication skills (59.9%), inefficiency in tasks (40.1%), and poor fund of medical knowledge (39.1%). The most common forms of program intervention were additional meetings to provide detailed feedback (93.9%), verbal warnings (78.7%), and formal written remediation plans (61.4%). Of the identified problem residents whose training status is known, 50% graduated or are on track to graduate, while the remaining 50% ultimately left their residency program for other endeavors. Of the 97 residents who departed their programs, 65% left voluntarily (most commonly for another specialty), and 35% were terminated (often ultimately training in another neurosurgery program). On multivariable logistic regression analysis, the following 3 factors were independently associated with departure of a problem resident from their residency program: dishonesty (OR 3.23, 95% CI 1.67–6.253), poor fund of medical knowledge (OR 2.54, 95% CI 1.47–4.40), and poor technical skill (OR 2.37, 95% CI 1.37–4.12).CONCLUSIONSThe authors’ findings represent the first study to characterize the nature of problem residents within neurosurgery. Identification of predictive risk factors, such as dishonesty, poor medical knowledge, and/or technical skill, may enable program directors to preemptively act and address such deficiencies in residents before departure from the program occurs. As half of the problem residents departed their programs, there remains an unmet need for further research regarding effective remediation strategies.
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Zhou MH, Dunn GP, Osbun JW, Cross DT, Moran CJ, Dacey RG, Kansagra AP. Direct puncture Onyx embolization of a large calvarial metastasis with intracranial extension: Case report. Interv Neuroradiol 2017; 24:220-224. [PMID: 29119877 DOI: 10.1177/1591019917740353] [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] [Indexed: 11/15/2022] Open
Abstract
We report a case of renal cell carcinoma (RCC) metastasis to the calvarium and describe a strategy for percutaneous embolization of hypervascular calvarial tumors with intracranial extension. An elderly patient with history of RCC presented with left-sided weakness. Imaging studies showed a large right frontoparietal calvarial mass with intra- and extracranial extension. The tumor was devascularized by direct puncture tumor embolization using Onyx 18, allowing subsequent operative resection without significant blood loss or the need for flap reconstruction of the scalp. Compared to more common endovascular approaches, direct-needle puncture embolization of transcalvarial masses may offer lower risk of injury to scalp vessels and underlying brain parenchyma.
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Affiliation(s)
- Minerva H Zhou
- 1 12275 School of Medicine, Washington University , St. Louis, MO, USA
| | - Gavin P Dunn
- 2 12275 Department of Neurological Surgery, Washington University , St. Louis, MO, USA.,3 Department of Pathology and Immunology, Washington University, St. Louis, MO, USA.,4 Center for Human Immunology and Immunotherapy Programs, Washington University, St. Louis, MO, USA
| | - Joshua W Osbun
- 2 12275 Department of Neurological Surgery, Washington University , St. Louis, MO, USA.,5 Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA.,6 Department of Neurology, Washington University, St. Louis, MO, USA
| | - DeWitte T Cross
- 2 12275 Department of Neurological Surgery, Washington University , St. Louis, MO, USA.,5 Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Christopher J Moran
- 2 12275 Department of Neurological Surgery, Washington University , St. Louis, MO, USA.,5 Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Ralph G Dacey
- 2 12275 Department of Neurological Surgery, Washington University , St. Louis, MO, USA
| | - Akash P Kansagra
- 2 12275 Department of Neurological Surgery, Washington University , St. Louis, MO, USA.,5 Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA.,6 Department of Neurology, Washington University, St. Louis, MO, USA
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Sun SQ, Cai C, Murphy RKJ, DeWees T, Dacey RG, Grubb RL, Rich KM, Zipfel GJ, Dowling JL, Leuthardt EC, Simpson JR, Robinson CG, Chicoine MR, Perrin RJ, Huang J, Kim AH. Radiation Therapy for Residual or Recurrent Atypical Meningioma: The Effects of Modality, Timing, and Tumor Pathology on Long-Term Outcomes. Neurosurgery 2017; 79:23-32. [PMID: 26645969 DOI: 10.1227/neu.0000000000001160] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Optimal use of stereotactic radiosurgery (SRS) vs external beam radiation therapy (EBRT) for treatment of residual/recurrent atypical meningioma is unclear. OBJECTIVE To analyze features associated with progression after radiation therapy. METHODS Fifty radiation-naive patients who received SRS or EBRT for residual and/or recurrent atypical meningioma were examined for predictors of progression using Cox regression and Kaplan-Meier analyses. RESULTS Thirty-two patients (64%) received adjuvant radiation after subtotal resection, 12 patients (24%) received salvage radiation after progression following subtotal resection, and 6 patients (12%) received salvage radiation after recurrence following gross total resection. Twenty-one patients (42%) received SRS (median 18 Gy), and 7 (33%) had tumor progression. Twenty-nine patients (58%) received EBRT (median 54 Gy), and 13 (45%) had tumor progression. Whereas tumor volume (P = .53), SRS vs EBRT (P = .45), and adjuvant vs salvage (P = .34) were not associated with progression after radiation therapy, spontaneous necrosis (hazard ratio [HR] = 82.3, P < .001), embolization necrosis (HR = 15.6, P = .03), and brain invasion (HR = 3.8, P = .008) predicted progression in univariate and multivariate analyses. Tumors treated with SRS/EBRT had 2- and 5-year actuarial locoregional control rates of 91%/88% and 71%/69%, respectively. Tumors with spontaneous necrosis, embolization necrosis, and no necrosis had 2- and 5-year locoregional control rates of 76%, 92%, and 100% and 36%, 73%, and 100%, respectively (P < .001). CONCLUSION This study suggests that necrosis may be a negative predictor of radiation response regardless of radiation timing or modality. ABBREVIATIONS AM, atypical meningiomaEBRT, external beam radiation therapyGTR, gross total resectionLC, locoregional controlOS, overall survivalPOE, preoperative embolizationRT, radiation therapySRS, stereotactic radiosurgerySTR, subtotal resection.
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Affiliation(s)
- Sam Q Sun
- ‡Washington University School of Medicine, St. Louis, Missouri; §Department of Pathology and Immunology, Washington University, St. Louis, Missouri; ¶Department of Neurosurgery, Washington University, St. Louis, Missouri; ‖Department of Radiation Oncology, Washington University, St. Louis, Missouri
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Kim DH, Dacey RG, Zipfel GJ, Berger MS, McDermott M, Barbaro NM, Shapiro SA, Solomon RA, Harbaugh R, Day AL. In Reply: Neurosurgical Education in a Changing Healthcare and Regulatory Environment: A Consensus Statement From 6 Programs. Neurosurgery 2017; 81:E47. [PMID: 28934443 DOI: 10.1093/neuros/nyx348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Dong H Kim
- Department of Neurosurgery The University of Texas Medical School at Houston Houston, Texas
| | - Ralph G Dacey
- Department of Neurosurgery Washington University School of Medicine St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery Washington University School of Medicine St. Louis, Missouri
| | - Mitchel S Berger
- Department of Neurological Surgery University of California, San Francisco San Francisco, California
| | - Michael McDermott
- Department of Neurological Surgery University of California, San Francisco San Francisco, California
| | - Nicholas M Barbaro
- Department of Neurological Surgery Indiana University Indianapolis, Indiana
| | - Scott A Shapiro
- Department of Neurological Surgery Indiana University Indianapolis, Indiana
| | - Robert A Solomon
- Department of Neurosurgery Columbia University New York, New York
| | - Robert Harbaugh
- Department of Neurosurgery Pennsylvania State University Hershey, Pennsylvania
| | - Arthur L Day
- Department of Neurosurgery The University of Texas Medical School at Houston Houston, Texas
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Derdeyn CP, Zipfel GJ, Zazulia AR, Davis PH, Prabhakaran S, Ivan CS, Aiyagari V, Sagar JR, Hantler N, Shinawi L, Lee JJ, Jafri H, Grubb RL, Miller JP, Dacey RG. Baseline Hemodynamic Impairment and Future Stroke Risk in Adult Idiopathic Moyamoya Phenomenon: Results of a Prospective Natural History Study. Stroke 2017; 48:894-899. [PMID: 28283605 PMCID: PMC8204377 DOI: 10.1161/strokeaha.116.014538] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 06/27/2016] [Revised: 01/09/2017] [Accepted: 01/17/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose was to test the hypothesis that increased oxygen extraction fraction (OEF), a marker of severe hemodynamic impairment measured by positron emission tomography, is an independent risk factor for subsequent ischemic stroke in this population. METHODS Adults with idiopathic moyamoya phenomena were recruited between 2005 and 2012 for a prospective, multicenter, blindly adjudicated, longitudinal cohort study. Measurements of OEF were obtained on enrollment. Subjects were followed up for the occurrence of ipsilateral ischemic stroke at 6-month intervals. Patients were censored at the time of surgical revascularization or at last follow-up. The primary analysis was time to ischemic stroke in the territory of the occlusive vasculopathy. RESULTS Forty-nine subjects were followed up during a median of 3.7 years. One of 16 patients with increased OEF on enrollment had an ischemic stroke and another had an intraparenchymal hemorrhage. Three of 33 patients with normal OEF had an ischemic stroke. On a per-hemisphere basis, 21 of 79 hemispheres with moyamoya vasculopathy had increased OEF at baseline. No ischemic strokes and one hemorrhage occurred in a hemisphere with increased OEF (n=21). Sixteen patients (20 hemispheres), including 5 with increased OEF at enrollment, were censored at a mean of 5.3 months after enrollment for revascularization surgery. CONCLUSIONS The risk of new or recurrent stroke was lower than expected. The low event rate, low prevalence of increased OEF, and potential selection bias introduced by revascularization surgery limit strong conclusions about the association of increased OEF and future stroke risk. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00629915.
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Affiliation(s)
- Colin P Derdeyn
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.).
| | - Gregory J Zipfel
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - Allyson R Zazulia
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - Patricia H Davis
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - Shyam Prabhakaran
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - Cristina S Ivan
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - Venkatesh Aiyagari
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - James R Sagar
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - Nancy Hantler
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - Lina Shinawi
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - John J Lee
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - Hussain Jafri
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - Robert L Grubb
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - J Philip Miller
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
| | - Ralph G Dacey
- From the Department of Radiology (C.P.D.), Department of Neurology (C.P.D., P.H.D.), and Department of Neurosurgery (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City; Department of Neurological Surgery (G.J.Z., R.L.G., R.G.D.), Department of Neurology (A.R.Z.), Department of Radiology (J.R.S., N.H., L.S., J.J.L., H.J.), and Division of Biostatistics (J.P.M.), Washington University School of Medicine, St Louis, MO; Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.P.); Department of Neurology, University of Indiana Medical School, Indianapolis (C.S.I.); and Department of Neurology, University of Texas Southwestern Medical School, Dallas (V.A.)
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Kim DH, Dacey RG, Zipfel GJ, Berger MS, McDermott M, Barbaro NM, Shapiro SA, Solomon RA, Harbaugh R, Day AL. Neurosurgical Education in a Changing Healthcare and Regulatory Environment: A Consensus Statement from 6 Programs. Neurosurgery 2017; 80:S75-S82. [DOI: 10.1093/neuros/nyw146] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 10/13/2016] [Indexed: 11/13/2022] Open
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Kim DH, Duco B, Wolterman D, Stokes C, Brace R, Solomon RA, Barbaro N, Westmark R, MacDougall D, Bean J, O’Leary J, Moayeri N, Dacey RG, Berger MS, Harbaugh R. A Review and Survey of Neurosurgeon–Hospital Relationships: Evolution and Options. Neurosurgery 2017; 80:S10-S18. [DOI: 10.1093/neuros/nyw171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 12/27/2016] [Indexed: 11/13/2022] Open
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Shah MN, Smith SE, Dierker DL, Herbert JP, Coalson TS, Bruck BS, Zipfel GJ, Van Essen DC, Dacey RG. The relationship of cortical folding and brain arteriovenous malformations. Neurovasc Imaging 2016; 2. [PMID: 28009020 PMCID: PMC5167380 DOI: 10.1186/s40809-016-0024-3] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background The pathogenesis of human intracranial arteriovenous malformations (AVMs) is not well understood; this study aims to quantitatively assess cortical folding in patients with these lesions. Methods Seven adult participants, 4 male and 3 female, with unruptured, surgically unresectable intracranial AVMs were prospectively enrolled in the study, with a mean age of 42.1 years and Spetzler-Martin grade range of II–IV. High-resolution brain MRI T1 and T2 sequences were obtained. After standard preprocessing, segmentation and registration techniques, three measures of cortical folding, the depth difference index (DDI), coordinate distance index (CDI) and gyrification index (GI)), were calculated for the affected and unaffected hemispheres of each subject as well as a healthy control subject set. Results Of the three metrics, CDI, DDI and GI, used for cortical folding assessment, none demonstrated significant differences between the participants and previously studied healthy adults. There was a significant negative correlation between the DDI ratio between affected and unaffected hemispheres and AVM volume (correlation coefficient r = −0.74, p = 0.04). Conclusion This study is the first to quantitatively assess human brain cortical folding in the presence of intracranial AVMs and no significant differences between AVM-affected versus unaffected hemispheres were found in a small dataset. We suggest longitudinal, larger human MRI-based cortical folding studies to assess whether AVMs are congenital lesions of vascular development or de novo, dynamic lesions.
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Affiliation(s)
- Manish N Shah
- Departments of Pediatric Surgery and Neurosurgery, McGovern Medical School at UT Health and UT MD Anderson Cancer Center, Pediatric Neurosurgery, 6431 Fannin St., MSB 5.144, Houston, TX 77030, USA
| | - Sarah E Smith
- Department of Neuroscience, Washington University, 660 S. Euclid Ave, St. Louis, MO 63110, USA
| | - Donna L Dierker
- Department of Neuroscience, Washington University, 660 S. Euclid Ave, St. Louis, MO 63110, USA
| | - Joseph P Herbert
- Division of Neurosurgery, University of Missouri-Columbia, One Hospital Drive, 314 McHaney Hall, Columbia, MO 65212, USA
| | - Timothy S Coalson
- Department of Neuroscience, Washington University, 660 S. Euclid Ave, St. Louis, MO 63110, USA
| | - Brent S Bruck
- Department of Neurological Surgery, Washington University, 660 S. Euclid Ave, St. Louis, MO 63110, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University, 660 S. Euclid Ave, St. Louis, MO 63110, USA
| | - David C Van Essen
- Department of Neuroscience, Washington University, 660 S. Euclid Ave, St. Louis, MO 63110, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University, 660 S. Euclid Ave, St. Louis, MO 63110, USA
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Kathleen Bandt S, Dacey RG. Reverberation index: a novel metric by which to quantify the impact of a scientific entity on a given field. J Neurosurg 2016; 127:694-698. [PMID: 27715434 DOI: 10.3171/2016.7.jns152387] [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] [Indexed: 11/06/2022]
Abstract
The authors propose a novel bibilometric index, the reverberation index (r-index), as a comparative assessment tool for use in determining differential reverberation between scientific fields for a given scientific entity. Conversely, this may allow comparison of 2 similar scientific entities within a single scientific field. This index is calculated using a relatively simple 3-step process. Briefly, Thompson Reuters' Web of Science is used to produce a citation report for a unique search parameter (this may be an author, journal article, or topical key word). From this citation report, a list of citing journals is retrieved from which a weighted ratio of citation patterns across journals can be calculated. This r-index is then used to compare the reverberation of the original search parameter across different fields of study or wherever a comparison is required. The advantage of this novel tool is its ability to transcend a specific component of the scientific process. This affords application to a diverse range of entities, including an author, a journal article, or a topical key word, for effective comparison of that entity's reverberation within a scientific arena. The authors introduce the context for and applications of the r-index, emphasizing neurosurgical topics and journals for illustration purposes. It should be kept in mind, however, that the r-index is readily applicable across all fields of study.
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Affiliation(s)
- S Kathleen Bandt
- Department of Neurological Surgery, Yale University School of Medicine, New Haven, Connecticut; and
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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Greenberg JK, Guniganti R, Arias EJ, Desai K, Washington CW, Yan Y, Weng H, Xiong C, Fondahn E, Cross DT, Moran CJ, Rich KM, Chicoine MR, Dhar R, Dacey RG, Derdeyn CP, Zipfel GJ. Predictors of 30-day readmission after aneurysmal subarachnoid hemorrhage: a case-control study. J Neurosurg 2016; 126:1847-1854. [PMID: 27494820 DOI: 10.3171/2016.5.jns152644] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 11/06/2022]
Abstract
OBJECTIVE Despite persisting questions regarding its appropriateness, 30-day readmission is an increasingly common quality metric used to influence hospital compensation in the United States. However, there is currently insufficient evidence to identify which patients are at highest risk for readmission after aneurysmal subarachnoid hemorrhage (SAH). The objective of this study was to identify predictors of 30-day readmission after SAH, to focus preventative efforts, and to provide guidance to funding agencies seeking to risk-adjust comparisons among hospitals. METHODS The authors performed a case-control study of 30-day readmission among aneurysmal SAH patients treated at a single center between 2003 and 2013. To control for geographic distance from the hospital and year of treatment, the authors randomly matched each case (30-day readmission) with approximately 2 SAH controls (no readmission) based on home ZIP code and treatment year. They evaluated variables related to patient demographics, socioeconomic characteristics, comorbidities, presentation severity (e.g., Hunt and Hess grade), and clinical course (e.g., need for gastrostomy or tracheostomy, length of stay). Conditional logistic regression was used to identify significant predictors, accounting for the matched design of the study. RESULTS Among 82 SAH patients with unplanned 30-day readmission, the authors matched 78 patients with 153 nonreadmitted controls. Age, demographics, and socioeconomic factors were not associated with readmission. In univariate analysis, multiple variables were significantly associated with readmission, including Hunt and Hess grade (OR 3.0 for Grade IV/V vs I/II), need for gastrostomy placement (OR 2.0), length of hospital stay (OR 1.03 per day), discharge disposition (OR 3.2 for skilled nursing vs other disposition), and Charlson Comorbidity Index (OR 2.3 for score ≥ 2 vs 0). However, the only significant predictor in the multivariate analysis was discharge to a skilled nursing facility (OR 3.2), and the final model was sensitive to criteria used to enter and retain variables. Furthermore, despite the significant association between discharge disposition and readmission, less than 25% of readmitted patients were discharged to a skilled nursing facility. CONCLUSIONS Although discharge disposition remained significant in multivariate analysis, most routinely collected variables appeared to be weak independent predictors of 30-day readmission after SAH. Consequently, hospitals interested in decreasing readmission rates may consider multifaceted, cost-efficient interventions that can be broadly applied to most if not all SAH patients.
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Affiliation(s)
| | | | | | | | | | | | - Hua Weng
- Division of Biostatistics, Washington University School of Medicine in St. Louis, Missouri; and
| | - Chengjie Xiong
- Division of Biostatistics, Washington University School of Medicine in St. Louis, Missouri; and
| | | | - DeWitte T Cross
- Departments of 1 Neurological Surgery.,Mallinckrodt Institute of Radiology, and
| | - Christopher J Moran
- Departments of 1 Neurological Surgery.,Mallinckrodt Institute of Radiology, and
| | | | | | | | | | - Colin P Derdeyn
- Departments of 1 Neurological Surgery.,Neurology.,Mallinckrodt Institute of Radiology, and.,Departments of Radiology, Neurology, and Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Abstract
OBJECTIVE Colloid cysts are rare, histologically benign lesions that may result in obstructive hydrocephalus and death. Understanding the natural history of colloid cysts has been challenging given their low incidence and the small number of cases in most reported series. This has complicated efforts to establish reliable prognostic factors and surgical indications, particularly for asymptomatic patients with incidental lesions. Risk factors for obstructive hydrocephalus in the setting of colloid cysts remain poorly defined, and there are no grading scales on which to develop standard management strategies. METHODS The authors performed a single-center retrospective review of all cases of colloid cysts of the third ventricle treated over nearly 2 decades at Washington University. Univariate analysis was used to identify clinical, imaging, and anatomical factors associated with 2 outcome variables: symptomatic clinical status and presentation with obstructive hydrocephalus. A risk-prediction model was defined using bootstrapped logistic regression. Predictive factors were then combined into a simple 5-point clinical scale referred to as the Colloid Cyst Risk Score (CCRS), and this was evaluated with receiver-operator characteristics. RESULTS The study included 163 colloid cysts, more than half of which were discovered incidentally. More than half of the incidental cysts (58%) were followed with surveillance neuroimaging (mean follow-up 5.1 years). Five patients with incidental cysts (8.8%) progressed and underwent resection. No patient with an incidental, asymptomatic colloid cyst experienced acute obstructive hydrocephalus or sudden neurological deterioration in the absence of antecedent trauma. Nearly half (46.2%) of symptomatic patients presented with hydrocephalus. Eight patients (12.3%) presented acutely, and there were 2 deaths due to obstructive hydrocephalus and herniation. The authors identified several factors that were strongly correlated with the 2 outcome variables and defined third ventricle risk zones where colloid cysts can cause obstructive hydrocephalus. No patient with a lesion outside these risk zones presented with obstructive hydrocephalus. The CCRS had significant predictive capacity for symptomatic clinical status (area under the curve [AUC] 0.917) and obstructive hydrocephalus (AUC 0.845). A CCRS ≥ 4 was significantly associated with obstructive hydrocephalus (p < 0.0001, RR 19.4). CONCLUSIONS Patients with incidentally discovered colloid cysts can experience both lesion enlargement and symptom progression or less commonly, contraction and symptom regression. Incidental lesions rarely cause acute obstructive hydrocephalus or sudden neurological deterioration in the absence of antecedent trauma. Nearly one-half of patients with symptomatic colloid cysts present with obstructive hydrocephalus, which has an associated 3.1% risk of death. The CCRS is a simple 5-point clinical tool that can be used to identify symptomatic lesions and stratify the risk of obstructive hydrocephalus. External validation of the CCRS will be necessary before objective surgical indications can be established. Surgical intervention should be considered for all patients with CCRS ≥ 4, as they represent the high-risk subgroup.
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Affiliation(s)
| | | | | | - Franz J Wippold
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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Sylvester PT, Moran CJ, Derdeyn CP, Cross DT, Dacey RG, Zipfel GJ, Kim AH, Uppaluri R, Haughey BH, Tempelhoff R, Rich KM, Schneider J, Chole RA, Chicoine MR. Endovascular management of internal carotid artery injuries secondary to endonasal surgery: case series and review of the literature. J Neurosurg 2016; 125:1256-1276. [PMID: 26771847 DOI: 10.3171/2015.6.jns142483] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Internal carotid artery (ICA) injury is a rare but severe complication of endonasal surgery. The authors describe their endovascular experience managing ICA injuries after transsphenoidal surgery; they review and summarize the current literature regarding endovascular techniques; and they propose a treatment algorithm based on the available evidence. METHODS A retrospective review of 576 transsphenoidal pituitary adenoma resections was performed. Cases of ICA injury occurring at our institution and transfers from other hospitals were evaluated. Endovascular treatments for ICA injury reported in the literature were also reviewed and summarized. RESULTS Seven cases were identified from the institutional cohort (mean age 46.3 years, mean follow-up 43.4 months [1-107 months]) that received endovascular treatment for ICA injury. Five injuries occurred at our institution (5 [0.9%] of 576), and 2 injuries occurred at outside hospitals. Three patients underwent ICA sacrifice by coil placement, 2 underwent lesion embolization (coil or stent-assisted coil placement), and 2 underwent endoluminal reconstruction (both with flow diversion devices). Review of the literature identified 98 cases of ICA injury treated with endovascular methods. Of the 105 total cases, 46 patients underwent ICA sacrifice, 28 underwent lesion embolization, and 31 underwent endoluminal reconstruction. Sacrifice of the ICA proved a durable solution in all cases; however, the rate of persistent neurological complications was relatively high (10 [21.7%] of 46). Lesion embolization was primarily performed by coil embolization without stenting (16 cases) and stent-assisted coiling (9 cases). Both techniques had a relatively high rate of at least some technical complication (6 [37.5%] of 16 and 5 [55.6%] of 9, respectively) and major technical complications (i.e., injury, new neurological deficit, or ICA sacrifice) (5 [31.3%] of 16 and 2 [22.2%] of 9, respectively). Endoluminal reconstruction was performed by covered stent (24 cases) and flow diverter (5 cases) placement. Covered stents showed a reasonably high rate of technical complications (10 [41.7%] of 24); however, 8 of these problems were resolved, leaving a small percentage with major technical complications (2 [8.3%] of 24). Flow diverter placement was also well tolerated, with only 1 minor technical complication. CONCLUSIONS Endovascular treatments including vessel sacrifice, coil embolization (with or without stent assistance), and endoluminal reconstruction offer a tailored approach to ICA injury management after endonasal surgery. Vessel sacrifice remains the definitive treatment for acute, uncontrolled bleeding; however, vessel preservation techniques should be considered carefully in select patients. Multiple factors including vascular anatomy, injury characteristics, and risk of dual antiplatelet therapy should guide best treatment, but more study is needed (particularly with flow diverters) to refine this decision-making process. Ideally, all endovascular treatment options should be available at institutions performing endonasal surgery.
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Affiliation(s)
| | - Christopher J Moran
- Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
| | - Colin P Derdeyn
- Departments of 1 Neurosurgery.,Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
| | - DeWitte T Cross
- Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
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46
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Affiliation(s)
- Ralph G. Dacey
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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47
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Murata T, Dietrich HH, Horiuchi T, Hongo K, Dacey RG. Mechanisms of magnesium-induced vasodilation in cerebral penetrating arterioles. Neurosci Res 2015; 107:57-62. [PMID: 26712324 DOI: 10.1016/j.neures.2015.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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: 06/17/2015] [Revised: 11/16/2015] [Accepted: 12/09/2015] [Indexed: 01/14/2023]
Abstract
We investigated in cerebral penetrating arterioles the signaling mechanisms and dose-dependency of extracellular magnesium-induced vasodilation and also its vasodilatory effects in vessels preconstricted with agonists associated with delayed cerebral vasospasm following SAH. Male rat penetrating arterioles were cannulated. Their internal diameters were monitored. To investigate mechanisms of magnesium-induced vasodilation, inhibitors of endothelial function, potassium channels and endothelial impairment were tested. To simulate cerebral vasospasm we applied several spasmogenic agonists. Increased extracellular magnesium concentration produced concentration-dependent vasodilation, which was partially attenuated by non-specific calcium-sensitive potassium channel inhibitor tetraethylammonium, but not by other potassium channel inhibitors. Neither the nitric oxide synthase inhibitor L-NNA nor endothelial impairment induced by air embolism reduced the dilation. Although the magnesium-induced vasodilation was slightly attenuated by the spasmogen ET-1, neither application of PF2α nor TXA2 analog effect the vasodilation. Magnesium induced a concentration- and smooth muscle cell-dependent dilation in cerebral penetrating arterioles. Calcium-sensitive potassium channels of smooth muscle cells may play a key role in magnesium-induced vasodilation. Magnesium also dilated endothelium-impaired vessels as well as vessels preconstricted with spasmogenic agonists. These results provide a fundamental background for the clinical use of magnesium, especially in treatment against delayed cerebral ischemia or vasospasm following SAH.
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Affiliation(s)
- Takahiro Murata
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390-8621, Japan.
| | - Hans H Dietrich
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, United States; Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, United States
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49
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Affiliation(s)
- Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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50
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Arias EJ, Vajapey S, Reynolds MR, Chicoine MR, Rich KM, Dacey RG, Dorward IG, Derdeyn CP, Moran CJ, Cross DT, Zipfel GJ, Dhar R. Utility of Screening for Cerebral Vasospasm Using Digital Subtraction Angiography. Stroke 2015; 46:3137-41. [PMID: 26405204 DOI: 10.1161/strokeaha.115.010081] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 05/15/2015] [Accepted: 08/06/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral arterial vasospasm (CVS) is a common complication of aneurysmal subarachnoid hemorrhage strongly associated with neurological deterioration and delayed cerebral ischemia (DCI). The utility of screening for CVS as a surrogate for early detection of DCI, especially in patients without clinical signs of DCI, remains uncertain. METHODS We performed a retrospective analysis of 116 aneurysmal subarachnoid hemorrhage patients who underwent screening digital subtraction angiography to determine the association of significant CVS and subsequent development of DCI. Patients were stratified into 3 groups: (1) no symptoms of DCI before screening, (2) ≥1 episodes of suspected DCI symptoms before screening, and (3) unable to detect symptoms because of poor examination. RESULTS Patients asymptomatic before screening had significantly lower rates of CVS (18%) compared with those with transient symptoms of DCI (60%; P<0.0001). None of the 79 asymptomatic patients developed DCI after screening, regardless of digital subtraction angiography findings, compared with 56% of those with symptoms (P<0.0001). Presence of CVS was significantly associated with DCI in those with transient symptoms and in those whose examinations did not permit clear assessment (odds ratio 16.0, 95% confidence interval 2.2-118.3, P=0.003). CONCLUSIONS Patients asymptomatic before screening have low rates of CVS and seem to be at negligible risk of developing DCI. Routine screening of asymptomatic patients seems to have little utility. Screening may still be considered in patients with possible symptoms of DCI or those with examinations too poor to clinically detect symptoms because finding CVS may be useful for risk stratification and guiding management.
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Affiliation(s)
- Eric J Arias
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO.
| | - Sravya Vajapey
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Matthew R Reynolds
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Michael R Chicoine
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Keith M Rich
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Ralph G Dacey
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Ian G Dorward
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Colin P Derdeyn
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Christopher J Moran
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - DeWitte T Cross
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Gregory J Zipfel
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
| | - Rajat Dhar
- From the Department of Neurological Surgery (E.J.A., S.V., M.R.R., M.R.C., K.M.R., R.G.D., I.G.D., C.P.D., C.J.M., D.T.C., G.J.Z.), Department of Neurology (C.P.D., C.J.M., D.T.C., G.J.Z., R.D.), and Mallinckrodt Institute of Radiology (C.P.D.,C.J.M., D.T.C.), Washington University School of Medicine, St Louis, MO
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