Monday, October 27, 2014

Evidence-Based Assessment of Well-Established Interventions: The Parachute and the Epidural Hematoma

Neurosurgery - Current Issue

BACKGROUND: The methods of evidence-based medicine are a relatively recent development in the understanding of clinical practice. They are criticized as not providing support for interventions long held to be highly effective based on experience that predated the availability of evidence-based analysis. OBJECTIVE: To determine if the methods of evidence-based medicine can be successfully applied to interventions established before those methods were developed. METHODS: Systematic review of English language literature on the natural history and treated prognosis of acute epidural hematoma and analysis of existing data on mortality associated with parachute use. DATA SOURCES: Sources of data included Medline, Old Medline, Science Citation Index, British and US Parachute Associations, and Federal Aviation Administration and National Transportation Safety Board databases (both of the United States). Also included were national databases reporting mortality and total number of parachute uses. RESULTS: The estimated mortality of falling from an airplane with an ineffective parachute is 74% (69-79). Mortality associated with effective parachute deployment is between 0.0011% and 0.0017%. For acute epidural hematoma, estimated mortality is 98.54% (95.1-99.9) without treatment and 12.9% (10.5-15.3) with treatment. The number needed to treat to prevent 1 death for the parachute is estimated to be 1.35 (1.27-1.45) and for epidural hematoma 1.17 (1.13-1.22) (95% binomial confidence intervals in parentheses). CONCLUSION: The methods of evidence-based medicine are robust and can deal with interventions of great face validity and those considered well established before such methods were well developed. We propose initial criteria for evaluating the quality of evidence supporting long-established interventions. ABBREVIATIONS: ARR, absolute risk reduction CI, confidence interval EC-IC, extracranial-intracranial FAA, Federal Aviation Administration NNT, number needed to treat NTSB, National Transportation Safety Board RCT, randomized clinical trial.

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/11000/Evidence_Based_Assessment_of_Well_Established.9.aspx

Surgery of Intradural Extramedullary Tumors: Retrospective Analysis of 107 Cases

Neurosurgery Blog

Tarantino, Roberto MD*; Donnarumma, Pasquale MD*; Nigro, Lorenzo MD*; Rullo, Marika PhD‡; Santoro, Antonio MD*; Delfini, Roberto MD*
*Department of Neurology and Psychiatry, Division of Neurosurgery, and

‡Department of Psychology of Developmental and Socialization Processes, Sapienza University of Rome, Rome, Italy

BACKGROUND: Intradural extramedullary tumors (IDEMTs) are uncommon lesions that cause pain and neurological deficits.

OBJECTIVE: To evaluate the effects of surgery for IDEMTs.

METHODS: This cohort study recruited all patients operated on for IDEMTs at the Department of Neurology and Psychiatry of Sapienza University of Rome from January 2003 to January 2013. The analysis was conducted on clinical records evaluation over a 1-year follow-up. The Graphic Rating Scale was used to assess pain. Neurological deficits were detected through neurological examination. Quality of life was evaluated with the EuroQol (EQ-5D). Statistical interpretation of the data was performed with SPSS version 19 software.

RESULTS: One hundred seven patients were recruited. Three were lost to follow-up. Patients reported lower level of pain 1 year after surgery (before surgery, 6.05; after surgery, 3.65). Mean comparison showed a significant decrease of −2.400 (P < .001). Ninety-two patients (88.5%) were neurologically asymptomatic 1 year after surgery. Only 12 patients (11.5%) presented with a deficit, with a global decrease of 39% (χ2 = 27.6; P < .005). The quality of life in patients was middle to high (mean rating of EQ-5D visual analog score, 61.78%). The lowest levels of quality of life were found in patients with sphincter dysfunctions (mean, 33.4).

CONCLUSION: Surgery for IDEMTs has a good outcome. Patients reported lower levels of pain and a drastic reduction in neurological symptoms 1 year after surgery. The quality of life is middle to high. It is influenced mainly by the neurological outcome.

http://journals.lww.com/neurosurgery/Fulltext/2014/11000/Surgery_of_Intradural_Extramedullary_Tumors__.3.aspx

The post Surgery of Intradural Extramedullary Tumors: Retrospective Analysis of 107 Cases appeared first on NEUROSURGERY BLOG.

Original Article: http://neurocirurgiabr.com/surgery-of-intradural-extramedullary-tumors-retrospective-analysis-of-107-cases/?utm_source=rss&utm_medium=rss&utm_campaign=surgery-of-intradural-extramedullary-tumors-retrospective-analysis-of-107-cases

Reoperation for Recurrent High-Grade Glioma: A Current Perspective of the Literature

Neurosurgery - Most Popular Articles

Optimal treatment for recurrent high-grade glioma continues to evolve. Currently, however, there is no consensus in the literature on the role of reoperation in the management of these patients. In this analysis, we reviewed the literature to examine the role of reoperation in patients with World Health Organization grade III or IV recurrent gliomas, focusing on how reoperation affects outcome, perioperative complications, and quality of life. An extensive literature review was performed through the use of the PubMed and Ovid Medline databases for January 1980 through August 2013. A total 31 studies were included in the final analysis. Of the 31 studies with significant data from single or multiple institutions, 29 demonstrated a survival benefit or improved functional status after reoperation for recurrent high-grade glioma. Indications for reoperation included new focal neurological deficits, tumor mass effect, signs of elevated intracranial pressure, headaches, increased seizure frequency, and radiographic evidence of tumor progression. Age was not a contraindication to reoperation. Time interval of at least 6 months between operations and favorable performance status (Karnofsky Performance Status score ≥70) were important predictors of benefit from reoperation. Extent of resection at reoperation improved survival, even in patients with subtotal resection at initial operation. Careful patient selection such as avoiding those individuals with poor performance status and bevacizumab within 4 weeks of surgery is important. Although limited to retrospective analysis and patient selection bias, mounting evidence suggests a survival benefit in patients receiving a reoperation at the time of high-grade glioma recurrence. ABBREVIATIONS: EOR, extent of resection GTR, gross total resection KPS, Karnofsky Performance Status STR, subtotal resection WHO, World Health Organization

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/11000/Reoperation_for_Recurrent_High_Grade_Glioma___A.1.aspx

Surgical Site Infections in Spine Surgery: Identification of Microbiologic and Surgical Characteristics in 239 Cases

Neurosurgery Blog

Surgical Site Infections in Spine Surgery: Identification of Microbiologic and Surgical Characteristics in 239 Cases

Abdul-Jabbar, Amir MD^*; Berven, Sigurd H. MD^†; Hu, Serena S. MD^†; Chou, Dean MD^‡; Mummaneni, Praveen V. MD^‡; Takemoto, Steven PhD^†; Ames, Christopher MD^‡; Deviren, Vedat MD^†; Tay, Bobby MD^†; Weinstein, Phil MD^‡; Burch, Shane MD^†; Liu, Catherine MD^§

Study Design. Retrospective analysis.

Objective. The objective of this study was to describe the microbiology of surgical site infection (SSI) in spine surgery and relationship with surgical management characteristics.

Summary of Background Data. SSI is an important complication of spine surgery that results in significant morbidity. A comprehensive and contemporary understanding of the microbiology of postoperative spine infections is valuable to direct empiric antimicrobial treatment and prophylaxis and other infection prevention strategies.

Methods. All cases of spinal surgery associated with SSI between July 2005 and November 2010 were identified by the hospital infection control surveillance program using Centers for Disease Control National Health Safety Network criteria. Surgical characteristics and microbiologic data for each case were gathered by direct medical record review.

Results. Of 7529 operative spine cases performed between July 2005 and November 2010, 239 cases of SSI were identified. The most commonly isolated pathogen was Staphylococcus aureus (45.2%), followed by Staphylococcus epidermidis (31.4%). Methicillin-resistant organisms accounted for 34.3% of all SSIs and were more common in revision than in primary surgical procedures (47.4% vs. 28.0%, P = 0.003). Gram-negative organisms were identified in 30.5% of the cases. Spine surgical procedures involving the sacrum were significantly associated with gram-negative organisms (P < 0.001) and polymicrobial infections (P = 0.020). Infections due to gram-negative organisms (P = 0.002) and Enterococcus spp. (P = 0.038) were less common in surgical procedures involving the cervical spine. Cefazolin-resistant gram-negative organisms accounted for 61.6% of all gram-negative infections and 18.8% of all SSIs.

Conclusion. Although gram-positive organisms predominated, gram-negative organisms accounted for a sizeable portion of SSI, particularly among lower lumbar and sacral spine surgical procedures. Nearly half of infections in revision surgery were due to a methicillin-resistant organism. These findings may help guide choice of empiric antibiotics while awaiting culture data and antimicrobial prophylaxis strategies in specific spine surgical procedures.

http://journals.lww.com/spinejournal/Abstract/2013/10150/Surgical_Site_Infections_in_Spine_Surgery_.15.aspx

The post Surgical Site Infections in Spine Surgery: Identification of Microbiologic and Surgical Characteristics in 239 Cases appeared first on NEUROSURGERY BLOG.

Original Article: http://neurocirurgiabr.com/surgical-site-infections-in-spine-surgery-identification-of-microbiologic-and-surgical-characteristics-in-239-cases/?utm_source=rss&utm_medium=rss&utm_campaign=surgical-site-infections-in-spine-surgery-identification-of-microbiologic-and-surgical-characteristics-in-239-cases

Can Viruses Treat Cancer?

Scientific American: Mind and Brain

For some cancer patients, viruses engineered to zero in on tumor cells work like a wonder drug. The task now is to build on this success

-- Read more on ScientificAmerican.com

Original Article: http://www.scientificamerican.com/article/can-viruses-treat-cancer/

Breast cancer in Wilms tumor survivors: New insights into primary and secondary prevention

Cancer

Pediatric oncology providers should closely evaluate their female survivors of Wilms tumor for risk factors for the development of breast cancer, including chest radiography (even at doses <20 gray), age >10 years at the time of Wilms tumor diagnosis, and, possibly, radiotherapy to the flank. Those patients deemed to be at high risk should undergo breast cancer surveillance with mammography, breast magnetic resonance imaging, or both starting at age 25 years.

Original Article: http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1002/cncr.28906

Newman's Notes: Alteplase for Ischemic Stroke (CME/CE)

MedPage Today Neurology

(MedPage Today) -- Meta-analyses of alteplase for ischemic stroke debunked for high or unreported heterogeneity.

Original Article: http://www.medpagetoday.com/Cardiology/Strokes/48256

Teaching NeuroImages: Massive cerebral edema after CT myelography: An optical illusion

Neurology recent issues

A 74-year-old woman underwent myelography with iohexol to exclude a CSF leak. Three days later, her son noticed mild facial asymmetry and took her back to the hospital. Neurologic status was at baseline except for minimal left nasolabial flattening. Initial head CT appeared to show diffuse cerebral edema (figure, A), but the following morning the appearance had normalized (figure, B). Based on the spontaneous clinicoradiologic improvement, we hypothesize that an illusion of cerebral edema was caused by residual iohexol. Although not reported with iohexol, older agents can cause hyperdense gray matter and can accumulate in sulci.¹

Original Article: http://www.neurology.org/cgi/content/short/83/18/e170?rss=1

The 10-year anniversary of the Neurology Resident & Fellow Section: 2004-2014

Neurology recent issues

Over the past 10 years, the Neurology® Resident & Fellow Section (RFS) has served as an outlet for articles and other journal-related activities relevant to trainees. The RFS was founded in 2004 by Drs. Karen Johnston and Robert Griggs with a focus on academic topics such as training, practice, ethics, teaching, and international training experiences.¹ The initial goals were met and superseded as subsections have gradually evolved to cover current areas, including Emerging Subspecialties in Neurology, Clinical Reasoning, Right Brain, Child Neurology, Pearls & Oy-sters, International Issues, Education Research and Initiatives, Teaching NeuroImages (including both static images and videos), and Media and Book Reviews. In addition, submissions have grown in number and quality from 12 in 2004 to 481 in 2013, with a current acceptance rate at approximately 30% (figure). A full listing of the different subsections and other activities of the RFS can be found at http://www.neurology.org/site/feature/index.xhtml. Two excellent examples of articles from the RFS can be found in this issue of Neurology.

Original Article: http://www.neurology.org/cgi/content/short/83/18/1586?rss=1

Wednesday, October 22, 2014

Error in Intensive Care: Psychological Repercussions and Defense Mechanisms Among Health Professionals

Critical Care Medicine - Current Issue

Objective: To identify the psychological repercussions of an error on professionals in intensive care and to understand their evolution. To identify the psychological defense mechanisms used by professionals to cope with error. Design: Qualitative study with clinical interviews. We transcribed recordings and analysed the data using an interpretative phenomenological analysis. Setting: Two ICUs in the teaching hospitals of Besançon and Dijon (France). Subjects: Fourteen professionals in intensive care (20 physicians and 20 nurses). Interventions: None. Measurements and Main Results: We conducted 40 individual semistructured interviews. The participants were invited to speak about the experience of error in ICU. The interviews were transcribed and analyzed thematically by three experts. In the month following the error, the professionals described feelings of guilt (53.8%) and shame (42.5%). These feelings were associated with anxiety states with rumination (37.5%) and fear for the patient (23%); a loss of confidence (32.5%); an inability to verbalize one's error (22.5%); questioning oneself at a professional level (20%); and anger toward the team (15%). In the long term, the error remains fixed in memory for many of the subjects (80%); on one hand, for 72.5%, it was associated with an increase in vigilance and verifications in their professional practice, and on the other hand, for three professionals, it was associated with a loss of confidence. Finally, three professionals felt guilt which still persisted at the time of the interview. We also observed different defense mechanisms implemented by the professional to fight against the emotional load inherent in the error: verbalization (70%), developing skills and knowledge (43%), rejecting responsibility (32.5%), and avoidance (23%). We also observed a minimization (60%) of the error during the interviews. Conclusions: It is important to take into account the psychological experience of error and the defense mechanisms developed following an error because they appear to determine the professional's capacity to acknowledge and disclose his/her error and to learn from it.

Original Article: http://journals.lww.com/ccmjournal/Fulltext/2014/11000/Error_in_Intensive_Care___Psychological.7.aspx

Optimal hypofractionated conformal radiotherapy for large brain metastases in patients with high risk factors: a single-institutional prospective study

Radiation Oncology

Background: A single-institutional prospective study of optimal hypofractionated conformal radiotherapy for large brain metastases with high risk factors was performed based on the risk prediction of radiation-related complications. Methods: Eighty-eight patients with large brain metastases ?10?cm3 in critical areas treated from January 2010 to February 2014 using the CyberKnife were evaluated. The optimal dose and number of fractions were determined based on the surrounding brain volume circumscribed with a single dose equivalent (SDE) of 14?Gy (V14) to be less than 7?cm3 for individual lesions. Univariate and multivariate analyses were conducted. Results: As a result of optimal treatment, 92 tumors ranging from 10 to 74.6?cm3 (median, 16.2?cm3) in volume were treated with a median prescribed isodose of 57% and a median fraction number of five. In order to compare the results according to the tumor volume, the tumors were divided into the following three groups: 1) 10?19.9?cm3, 2) 20?29.9?cm3 and 3) ?30?cm3. The lesions were treated with a median prescribed isodose of 57%, 56% and 55%, respectively, and the median fraction number was five in all three groups. However, all tumors ?20?cm3 were treated with???five fractions. The median SDE of the maximum dose in the three groups was 47.2?Gy, 48.5?Gy and 46.5?Gy, respectively. Local tumor control was obtained in 90.2% of the patients, and the median survival was nine months, with a median follow-up period of seven months (range, 3-41 months). There were no significant differences in the survival rates among the three groups. Six tumors exhibited marginal recurrence 7-36 months after treatment. Ten patients developed symptomatic brain edema or recurrence of pre-existing edema, seven of whom required osmo-steroid therapy. No patients developed radiation necrosis requiring surgical resection. Conclusion: Our findings demonstrate that the administration of optimal hypofractionated conformal radiotherapy based on the dose-volume prediction of complications (risk line for hypofractionation), as well as Kjellberg?s necrosis risk line used in single-session radiosurgery, is effective and safe for large brain metastases or other lesions in critical areas.

Original Article: http://www.ro-journal.com/content/9/1/231

Radiotherapy versus Observation following surgical resection of Atypical Meningioma (the ROAM trial)

Neuro-Oncology - current issue

Original Article: http://neuro-oncology.oxfordjournals.org/cgi/content/short/16/11/1560?rss=1

Immunotherapy advances for glioblastoma

Neuro-Oncology - current issue

Survival for patients with glioblastoma, the most common high-grade primary CNS tumor, remains poor despite multiple therapeutic interventions including intensifying cytotoxic therapy, targeting dysregulated cell signaling pathways, and blocking angiogenesis. Exciting, durable clinical benefits have recently been demonstrated for a number of other challenging cancers using a variety of immunotherapeutic approaches. Much modern research confirms that the CNS is immunoactive rather than immunoprivileged. Preliminary results of clinical studies demonstrate that varied vaccine strategies have achieved encouraging evidence of clinical benefit for glioblastoma patients, although multiple variables will likely require systematic investigation before optimal outcomes are realized. Initial preclinical studies have also revealed promising results with other immunotherapies including cell-based approaches and immune checkpoint blockade. Clinical studies to evaluate a wide array of immune therapies for malignant glioma patients are being rapidly developed. Important considerations going forward include optimizing response assessment and identifiying correlative biomarkers for predict therapeutic benefit. Finally, the potential of complementary combinatorial immunotherapeutic regimens is highly exciting and warrants expedited investigation.

Original Article: http://neuro-oncology.oxfordjournals.org/cgi/content/short/16/11/1441?rss=1

Primary Intraventricular Central Nervous System Rhabdomyosarcoma

Pediatric Neurology

A 10 year old girl presented with one week of new-onset headache and vomiting. Neurologic examination revealed wide-based ataxic gait. Computed tomography (CT) demonstrated a primary intraventricular mass with obstructive hydrocephalus (Figure 1A). The mass showed reduced diffusivity and homogeneous enhancement on magnetic resonance imaging (MRI) (Figure 1B-E). The patient underwent gross total resection of the tumor. Pathology demonstrated a malignant tumor characterized by densely cellular sheets of large eccentrically-placed vesicular nuclei, brisk mitotic activity, and rare cytoplasmic cross-striations.

Original Article: http://www.pedneur.com/article/S0887-8994(14)00513-X/abstract?rss=yes

Blogs for neurosurgeons

Neurosurgery Blog

Blogs for neurosurgeons

Surg Neurol Int 2012, 3:62

Júlio Leonardo Barbosa Pereira¹, Pieter L Kubben², Lucas Alverne Freitas de Albuquerque¹, Gervásio Teles C de Carvalho¹, Atos Alves de Sousa³
¹ Department of Neurosurgery, Santa Casa Hospital of Belo Horizonte, MG, Brazil
² Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
³ Department of Neurosurgery, Santa Casa Hospital of Belo Horizonte; Lecturer at the Post-graduate and Research Program at Santa Casa Hospital of Belo Horizonte, MG, Brazil

Abstract

Blogs are useful tools to research and to disseminate information. As they allow people who do not have specific knowledge on the building of sites to post content on the internet, they turned out to be very popular. In the past years, there has been a rapid expansion of blogs on several subjects and nowadays there are over 156 million blogs online. Neurosurgery was not out of this wave, and several blogs related to it can be found on the internet. The objective of this paper is to describe, in general, the functions of a blog and to provide initial guidance for the creation and the adequate use of neurosurgical blogs. Some interesting blogs and their features are also listed as examples.

Keywords: Actualization, blog, internet, neurosurgery

How to cite this article:
Pereira JB, Kubben PL, Freitas de Albuquerque LA, de Carvalho GC, de Sousa AA. Blogs for neurosurgeons. Surg Neurol Int 2012;3:62

How to cite this URL:
Pereira JB, Kubben PL, Freitas de Albuquerque LA, de Carvalho GC, de Sousa AA. Blogs for neurosurgeons. Surg Neurol Int [serial online] 2012 [cited 2014 Oct 19];3:62. Available from: http://www.surgicalneurologyint.com/text.asp?2012/3/1/62/97006

The post Blogs for neurosurgeons appeared first on NEUROSURGERY BLOG.

Original Article: http://neurocirurgiabr.com/blogs-for-neurosurgeons-3/?utm_source=rss&utm_medium=rss&utm_campaign=blogs-for-neurosurgeons-3

Tuesday, October 21, 2014

Programa Consulta ao Doutor: Tumor Cerebral

Programa Consulta ao Doutor: Tumor Cerebral com Dr. Julio Pereira Neurocirurgião

http://www.youtube.com/watch?v=bHoD4GCU6t0&sns=em

Wednesday, October 15, 2014

Chlorhexidine's role in skin antisepsis: questioning the evidence-Author's reply.

Unbound MEDLINE | Lancet journal articles

Maki DG
Chlorhexidine's role in skin antisepsis: questioning the evidence-Author's reply. [Letter]
Lancet 2014 Oct 11; 384(9951):1345-6.

Original Article: http://www.unboundmedicine.com/medline/citation/25307839/Chlorhexidine's_role_in_skin_antisepsis:_questioning_the_evidence_Author's_reply_

Headache App (FREE)

Headache App (FREE)
https://appsto.re/us/iizeG.i

Monday, October 13, 2014

Neuroscientists use snail research to help explain "chemo brain"

Neurology News & Neuroscience News from Medical News Today

It is estimated that as many as half of patients taking cancer drugs experience a decrease in mental sharpness. While there have been many theories, what causes "chemo brain" has eluded scientists.

Original Article: http://www.medicalnewstoday.com/releases/283658.php

Tuesday, October 7, 2014

Factors identified that are associated with childhood brain tumors

Neurology News & Neuroscience News from Medical News Today

Older parents, birth defects, maternal nutrition and childhood exposure to CT scans and pesticides are increasingly being associated with brain tumors in children, according to new research from the...

Original Article: http://www.medicalnewstoday.com/releases/283447.php

Monday, October 6, 2014

[Editorial] Emotion-based medicine or evidence-based medicine?

The Lancet Oncology

The UK National Institute for Health and Care Excellence (NICE) is once again under the microscope because of recent recommendations for various cancer drugs. In the past 2 months, just one recommendation out of four has been positive. Nab-paclitaxel for metastatic pancreatic cancer (Sept 8, 2014); trastuzumab emtansine for HER2-positive breast cancer (Aug 7, 2014); and abiraterone for metastatic, hormone-resistant prostate cancer (Aug 14, 2014) have all been rejected on the grounds of insufficient cost-effectiveness.

Original Article: http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(14)70498-X/fulltext?rss=yes

Endoscopic extended transsphenoidal resection of craniopharyngiomas: nuances of neurosurgical technique

Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents

Neurosurgical Focus, Volume 37, Issue 4, Page E10, October 2014.
Endoscopic approaches to the midline ventral skull base have been extensively developed and refined for resection of cranial base tumors over the past several years. As these techniques have improved, both the degree of resection and complication rates have proven comparable to those for transcranial approaches, while visual outcomes may be better via endoscopic endonasal surgery and hospital stays and recovery times are often shorter. Yet for all of the progress made, the steep learning curve associated with these techniques has hampered more widespread implementation and adoption. The authors address this obstacle by coupling a thorough description of the technical nuances for endoscopic endonasal craniopharyngioma resection with detailed illustrations of the important steps in the operation. Traditionally, transsphendoidal approaches to craniopharyngiomas have been restricted to lesions mostly confined to the sella. However, recently, endoscopic endonasal resections are more frequently employed for extrasellar and purely third ventricle craniopharyngiomas, whose typical retrochiasmatic location makes them ideal candidates for endoscopic transnasal surgery. The endonasal endoscopic approach offers many advantages, including direct access to the long axis of the tumor, early tumor debulking with minimal manipulation of the optic apparatus, more precise visualization of tumor planes, particularly along the undersurface of the chiasm and the roof of the third ventricle, and a minimal-access corridor that obviates the need for brain retraction. Although much emphasis has been placed on technical tenets of exposure and "how to get there," this article focuses on nuances of tumor resection "when you are there." Three operative videos illustrate our discussion of technical tenets.

Original Article: http://thejns.org/doi/abs/10.3171/2014.7.FOCUS14364?ai=rw&mi=3ba5z2&af=R

Endoscopic endonasal optic nerve and orbital apex decompression for nontraumatic optic neuropathy: surgical nuances and review of the literature

Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents

Neurosurgical Focus, Volume 37, Issue 4, Page E19, October 2014.
Object While several approaches have been described for optic nerve decompression, the endoscopic endonasal route is gaining favor because it provides excellent exposure of the optic canal and the orbital apex in a minimally invasive manner. Very few studies have detailed the experience with nontraumatic optic nerve decompressions, whereas traumatic cases have been widely documented. Herein, the authors describe their preliminary experience with endoscopic endonasal decompression for nontraumatic optic neuropathies (NONs) to determine the procedure's efficacy and delineate its potential indications and limits. Methods The medical reports of patients who had undergone endoscopic endonasal optic nerve and orbital apex decompression for NONs at the Lyon University Neurosurgical Hospital in the period from January 2012 to March 2014 were reviewed. For all cases, clinical and imaging data on the underlying pathology and the patient, including demographics, preoperative and 6-month postoperative ophthalmological assessment results, symptom duration, operative details with video debriefing, as well as the immediate and delayed postoperative course, were collected from the medical records. Results Eleven patients underwent endoscopic endonasal decompression for NON in the multidisciplinary skull base surgery unit of the Lyon University Neurosurgical Hospital during the 27-month study period. The mean patient age was 53.4 years, and there was a clear female predominance (8 females and 3 males). Among the underlying pathologies were 4 sphenoorbital meningiomas (36%), 3 optic nerve meningiomas (27%), and 1 each of trigeminal neuroma (9%), orbital apex meningioma (9%), ossifying fibroma (9%), and inflammatory pseudotumor of the orbit (9%). Fifty-four percent of the patients had improved visual acuity at the 6-month follow-up. Only 1 patient whose sphenoorbital meningioma had been treated at the optic nerve atrophy stage continued to worsen despite surgical decompression. The 2 patients presenting with preoperative papilledema totally recovered. One case of postoperative epistaxis was successfully treated using balloon inflation, and 1 case of air swelling of the orbit spontaneously resolved. Conclusions Endoscopic endonasal optic nerve decompression is a safe, effective, and minimally invasive technique affording the restoration of visual function in patients with nontraumatic compressive processes of the orbital apex and optic nerve. The timing of decompression remains crucial, and patients should undergo such a procedure early in the disease course before optic atrophy.

Original Article: http://thejns.org/doi/abs/10.3171/2014.7.FOCUS14303?ai=rw&mi=3ba5z2&af=R

Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension

Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents

Neurosurgical Focus, Volume 37, Issue 4, Page E13, October 2014.
Object Skull base chondrosarcomas are slow-growing, locally invasive tumors that arise from the petroclival synchondrosis. These characteristics allow them to erode the clivus and petrous bone and slowly compress the contents of the posterior fossa progressively until the patient becomes symptomatic, typically from cranial neuropathies. Given the site of their genesis, surrounded by the petrous apex and the clival recess, these tumors can project to the middle fossa, cervical area, and posteriorly, toward the cerebellopontine angle (CPA). Expanded endoscopic endonasal approaches are versatile techniques that grant access to the petroclival synchondrosis, the core of these lesions. The ability to access multiple compartments, remove infiltrated bone, and achieve tumor resection without the need for neural retraction makes these techniques particularly appealing in the management of these complex lesions. Methods Analysis of the authors' database yielded 19 cases of skull base chondrosarcomas; among these were 5 cases with predominant CPA involvement. The electronic medical records of the 5 patients were retrospectively reviewed for age, sex, presentation, pre- and postoperative imaging, surgical technique, pathology, and follow-up. These cases were used to illustrate the surgical nuances involved in the endonasal resection of CPA chondrosarcomas. Results The male/female ratio was 1:4, and the patients' mean age was 55.2 ±11.2 years. All cases involved petrous bone and apex, with variable extensions to the posterior fossa and parapharyngeal space. The main clinical scenario was cranial nerve (CN) palsy, evidenced by diplopia (20%), ptosis (20%), CN VI palsy (20%), dysphagia (40%), impaired phonation (40%), hearing loss (20%), tinnitus (20%), and vertigo/dizziness (40%). Gross-total resection of the CPA component of the tumor was achieved in 4 cases (80%); near-total resection of the CPA component was performed in 1 case (20%). Two patients (40%) harbored high-grade chondrosarcomas. No patient experienced worsening neurological symptoms postoperatively. In 2 cases (40%), the symptoms were completely normalized after surgery. Conclusions Expanded endoscopic endonasal approaches appear to be safe and effective in the resection of select skull base chondrosarcomas; those with predominant CPA involvement seem particularly amenable to resection through this technique. Further studies with larger cohorts are necessary to test these preliminary impressions and to compare their effectiveness with the results obtained with open approaches.

Original Article: http://thejns.org/doi/abs/10.3171/2014.7.FOCUS14349?ai=rw&mi=3ba5z2&af=R

Surgical management of trigeminal schwannomas: defining the role for endoscopic endonasal approaches

Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents

Neurosurgical Focus, Volume 37, Issue 4, Page E17, October 2014.
Object Because multiple anatomical compartments are involved, the surgical management of trigeminal schwannomas requires a spectrum of cranial base approaches. The endoscopic endonasal approach to Meckel's cave provides a minimal access corridor for surgery, but few reports have assessed outcomes of the procedure or provided guidelines for case selection. Methods A prospectively acquired database of 680 endoscopic endonasal cases was queried for trigeminal schwannoma cases. Clinical charts, radiographic images, and long-term outcomes were reviewed to determine outcome and success in removing tumor from each compartment traversed by the trigeminal nerve. Results Four patients had undergone endoscopic resection of trigeminal schwannomas via the transpterygoid approach (mean follow-up 37 months). All patients had disease within Meckel's cave, and 1 patient had extension into the posterior fossa. Gross-total resection was achieved in 3 patients whose tumors were purely extracranial. One patient with combined Meckel's cave and posterior fossa tumor had complete resection of the extracranial disease and 52% resection of the posterior fossa disease. One patient with posterior fossa disease experienced a sixth cranial nerve palsy in addition to a corneal keratopathy from worsened trigeminal neuropathy. There were no CSF leaks. Over the course of the study, 1 patient with subtotal resection required subsequent stereotactic radiosurgery for disease progression within the posterior fossa. Conclusions Endoscopic endonasal approaches appear to be well suited for trigeminal schwannomas restricted to Meckel's cave and/or extracranial segments of the nerve. Lateral transcranial skull base approaches should be considered for patients with posterior fossa disease. Further multiinstitutional studies will be necessary for adequate power to help determine relative indications between endoscopic and transcranial skull base approaches.

Original Article: http://thejns.org/doi/abs/10.3171/2014.7.FOCUS14341?ai=rw&mi=3ba5z2&af=R

Endoscopic supraorbital eyebrow approach for the surgical treatment of extraaxialand intraaxial tumors

Journal of Neurosurgery: Neurosurgical FOCUS: Table of Contents

Neurosurgical Focus, Volume 37, Issue 4, Page E20, October 2014.
Object The supraorbital eyebrow approach is a minimally invasive technique that offers wide access to the anterior skull base region and parasellar area through asubfrontal corridor. The use of neuroendoscopy allows one to extend the approach further to the pituitary fossa, the anterior third ventricle, the interpeduncular cistern, the anterior and medial temporal lobe, and the middle fossa. The supraorbital approach involves a limited skin incision, with minimal soft-tissue dissection and a small craniotomy, thus carrying relatively low approach-related morbidity. Methods All consecutive patients who underwent the endoscopic supraorbital eyebrow approach were retrospectively analyzed for lesion location, pathology, length of stay, complications, and cosmetic results. Results During a 56-month period, 97 patients (mean age 58.5 years) underwent an endoscopic eyebrow approach to resect extra- and intraaxial brain lesions. The most common pathologies treated were meningiomas (n = 41); craniopharyngiomas (n = 22); dermoid tumors (n = 7); metastases (n = 4); gliomas (n = 3); and other miscellaneous frontal, parasellar, and midbrain (n = 23) lesions. The median length of postoperative hospital stay was 2.7 days (range 1–8 days). In 82 patients a total removal of the lesion was performed, while in 15 patients a near-total or subtotal removal was achieved. There were no postoperative hematomas, cerebrospinal fluid leaks, or severe neurological deficits, with the exception of 2 cases of visual deterioration and 1 case each of meningitis, stroke, and third cranial nerve paresis. Other complications directly related to the approach included 2 cases of skin burn as a direct result of heat transmission from the microscope light, 1 case of right frontal palsy, 2 cases of frontal numbness, and 1 case of bone remodeling 1 year after surgery. Conclusions The endoscopic supraorbital eyebrow approach is a safe and effective minimally invasive approach to remove extra- and intraaxial anterior skull base, parasellar, and frontal lesions, promoting a rapid recovery and short hospital stay. The location of the eyebrow incision demands a meticulous cosmetic closure, but, with proper technique, cosmetic results are excellent.

Original Article: http://thejns.org/doi/abs/10.3171/2014.7.FOCUS14203?ai=rw&mi=3ba5z2&af=R

Residual tumor volume and patient survival following reoperation for recurrent glioblastoma

Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 121, Issue 4, Page 802-809, October 2014.
Object Maximal safe tumor resection is part of the standard of care for patients with newly diagnosed glioblastoma. The role of reoperation in the care of patients with recurrent glioblastoma is less clear, and less than a quarter of patients undergo a second surgery. Previous studies have identified preoperative variables associated with the improved survival of patients following reoperation, and guidelines for the selection of patients for reoperation have been devised and validated. In this study, the authors analyzed the relative survival benefit of maximal safe tumor removal in a series of patients with recurrent glioblastoma who all underwent reoperation. Methods In this longitudinal study, the clinical and radiological data of 97 consecutive patients who underwent reoperation for recurrent glioblastoma were prospectively collected. Multiple regression analyses and Kaplan-Meier plotting were performed to identify pre- and postoperative clinical and radiological variables associated with increased survival following reoperation. Results The median postoperative survival of all patients following reoperation was 12.4 months (95% confidence interval [CI] 9.0–15.6 months). Multiple Cox regression analysis revealed that patients with large (> 3 cm3) residual tumors following reoperation had significantly decreased survival relative to those with residual tumors that were small (> 0–3 cm3; hazard ratio [HR] = 3.10, 95% CI 1.69–5.70; p < 0.001) or radiologically absent (0 cm3; HR = 5.82, 95% CI 2.98–11.37; p < 0.001). Large residual tumors had faster rates of subsequent regrowth than small (odds ratio [OR] = 4.22, 95% CI 1.19–14.97; p = 0.026) or radiologically absent (OR = 11.00, 95% CI 2.79–43.43; p = 0.001) residual tumors, and a faster regrowth rate was significantly associated with decreased survival (HR = 4.01, 95% CI 2.26–7.14; p < 0.001). Conclusions The overall survival of patients with recurrent glioblastoma who underwent reoperations increased with decreasing postoperative residual tumor volumes. For patients meeting prognostic criteria for reoperation, the surgical goal should be to minimize residual tumor volume to maximize overall survival. Clinical trial registration no.: NCT00060541 (ClinicalTrials.gov).

Original Article: http://thejns.org/doi/abs/10.3171/2014.6.JNS132038?ai=ru&mi=0&af=R