Integration of Chronological Age Does Not Improve the Performance of a Mixed-Effect Model Using Comorbidity Burden and Frailty to Predict 90-Day Readmission After Surgery for Degenerative Scoliosis.

OBJECTIVE: We evaluated the contributions of chronological age, comorbidity burden, and/or frailty in predicting 90-day readmission in patients undergoing degenerative scoliosis surgery. METHODS: Patients were identified through the Healthcare Cost and Utilization Project Nationwide Readmissions Database. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty-defining indicator. Comorbidity was assessed using the Elixhauser Comorbidity Index (ECI). Generalized linear mixed-effects models were created to predict readmission using age, frailty, and/or ECI. Area under the curve (AUC) was compared using DeLong's test. RESULTS: A total of 8104 patients were identified. Readmission rate was 9.8%, with infection representing the most common cause (3.5%). Our first model utilized chronological age, ECI, and/or frailty as primary predictors. The combination of ECI + frailty + age performed best, but the inclusion of chronological age did not significantly improve performance compared to ECI + frailty alone (AUC 0.603 vs. 0.599, P = 0.290). A second model using only chronological age and frailty as primary predictors performed better, however the inclusion of chronological age worsened performance when compared to frailty alone (AUC 0.747 vs. 0.743, P = 0.043). CONCLUSIONS: These data support frailty as a predictor of 90-day readmission within a nationally representative sample. Frailty alone performed better than combinations of ECI and age. Interestingly, the integration of chronological age did not dramatically improve the model's performance. Limitations include the use of a national registry and a single frailty index. This provides impetus to explore biological age, rather than chronological age, as a potential tool for surgical risk assessment.

Endoscopic endonasal approaches for reconstruction of traumatic anterior skull base fractures and associated cerebrospinal fistulas: patient series.

BACKGROUND: Post-traumatic cerebrospinal fluid (CSF) leaks of the anterior skull base may arise after traumatic brain injury (TBI). Onset of CSF rhinorrhea may be delayed after TBI and without prompt treatment may result in debilitating consequences. Operative repair of CSF leaks caused by anterior skull base fractures may be performed via open craniotomy or endoscopic endonasal approaches (EEAs). The authors' objective was to review their institutional experience after EEA for repair of TBI-related anterior skull base defects and CSF leaks. OBSERVATIONS: A retrospective review of prospectively collected data from a major level 1 trauma center was performed to identify patients with TBI who developed CSF rhinorrhea. Persistent or refractory post-traumatic CSF leaks and anterior skull base defects were repaired via EEA in four patients. Intrathecal fluorescein was administered before EEA in three patients (75%) to help aid identification of the fistula site(s). CSF leaks were eventually repaired in all patients, though one reoperation was required. During a mean follow-up of 8.75 months, there were no instances of recurrent CSF leakage. LESSONS: Refractory, traumatic CSF leaks may be effectively repaired via EEA using a multilayer approach and nasoseptal flap reconstruction, thereby potentially obviating the need for additional craniotomy in the post-TBI setting.

Accuracy and outcomes of diffusion tensor imaging tractography in resection for vestibular schwannoma for facial nerve preservation.

BACKGROUND: Impairment of facial nerve (FN) function is a common postoperative complication in surgical resections of Vestibular Schwannomas (VS). Diffusion tensor imaging (DTI) tractography creates in vivo imaging of the anatomical location of white matter tracts that can be preoperatively used to visualize the displaced FN. We present an analysis of patients who underwent DTI tractography imaging prior to VS resection. METHODS: Patient charts were reviewed from March 2012 to April 2015 who underwent DTI tractography prior to surgical resection for VS. Reliability of this measure was compared to the intraoperative FN location as determined by the surgeon. House Brackmann (HB) score was used to assess facial nerve function. RESULTS: A total of 11 patients were included with a mean age of 43 years (range: 19-64) and mean follow-up length of 11.9 months (range: 3.1-34.2). The average maximum tumor diameter was 2.82 cm (range: 1.7-4.2). DTI tractography was accurate in 90.9% (10/11) of patients. Postoperatively, 72.7% (8/11) had a HB score of I or II, 18.2% (2/11) had a HB score of III, and 9.1% (1/11) had a HB score of IV. CONCLUSIONS: Facial nerve visualization for VS resection can be accurately visualized using DTI tractography. This modality may lead to reduction of postoperative FN damage.

Bioengineered recombinant vault nanoparticles coupled with NY-ESO-1 glioma-associated antigens induce maturation of native dendritic cells.

PURPOSE: Glioblastoma prognosis remains grim despite maximal, multimodal management. Recent literature has demonstrated an increase in research devoted to experimental treatments, particularly those relying on the foundations of active immunotherapy with promising results. We hypothesize that the utilization of bioengineered recombinant vault nanoparticles coupled with glioma-associated antigens, such as the NY-ESO-1 peptide, may be capable of stimulating native dendritic cell (DC) maturation and inducing an anti-tumor response. METHODS: Immature DCs were cultured from the bone marrow of 4-6-week-old C57BL/6 mice. The three treatment groups consisted of: (1) DC and media, (2) DC with mCherry vault, and (3) DC with NYESO and vault. DC maturity was assessed via flow cytometric evaluation of CD11c, CD86, and MHC-II. Increase in CD86 Median Fluorescence Intensity (MFI) was analyzed in the CD11c+CD86+MHC-II+ population to determine the extent of maturation RESULTS: Our findings suggest that CP-MVP-NY-ESO-1-INT recombinant vault nanoparticles are efficiently bioengineered with exceptional integrity, are quickly internalized by immature DCs for antigen processing, and result in DC maturation. CONCLUSION: This study reports our preliminary results, which demonstrate the feasibility and progress regarding our immunotherapeutic technique utilizing NY-ESO-1 packaged vault nanoparticles to prime DCs for subsequent anti-cancer therapies.

Intratumor injection of CCL21-coupled vault nanoparticles is associated with reduction in tumor volume in an in vivo model of glioma.

PURPOSE: Glioblastoma (GBM) is the most common and malignant primary adult brain tumor. Current care includes surgical resection, radiation, and chemotherapy. Recent clinical trials for GBM have demonstrated extended survival using interventions such as tumor vaccines or tumor-treating fields. However, prognosis generally remains poor, with expected survival of 20 months after randomization. Chemokine-based immunotherapy utilizing CCL21 locally recruits lymphocytes and dendritic cells to enhance host antitumor response. Here, we report a preliminary study utilizing CPZ-vault nanoparticles as a vehicle to package, protect, and steadily deliver therapy to optimize CCL21 therapy in a murine flank model of GBM. METHODS: GL261 cells were subcutaneously injected into the left flank of eight-week-old female C57BL/6 mice. Mice were treated with intratumoral injections of either: (1) CCL21-packaged vault nanoparticles (CPZ-CCL21), (2) free recombinant CCL21 chemokine empty vault nanoparticles, (3) empty vault nanoparticles, or 4) PBS. RESULTS: The results of this study showed that CCL21-packaged vault nanoparticle injections can decrease the tumor volume in vivo. Additionally, this study showed mice injected with CCL21-packaged vault nanoparticle had the smallest average tumor volume and remained the only treatment group with a negative percent change in tumor volume. CONCLUSIONS: This preliminary study establishes vault nanoparticles as a feasible vehicle to increase drug delivery and immune response in a flank murine model of GBM. Future animal studies involving an intracranial orthotopic tumor model are required to fully evaluate the potential for CCL21-packaged vault nanoparticles as a strategy to bypass the blood brain barrier, enhance intracranial immune activity, and improve intracranial tumor control and survival.

Surgery versus stereotactic radiosurgery for the treatment of multiple meningiomas in neurofibromatosis type 2: illustrative case and systematic review.

Neurofibromatosis type 2 (NF2) is a genetic neoplastic disorder that presents with hallmark bilateral vestibular schwannomas and multiple meningiomas. Though the current standard of care for meningiomas includes surgery, the multiplicity of meningiomas in NF2 patients renders complete resection of all developing lesions infeasible. Stereotactic radiosurgery (SRS) may be a viable non-invasive therapeutic alternative to surgery. We describe a particularly challenging case in a 39-year-old male with over 120 lesions who underwent more than 30 surgical procedures, and review the literature. We also searched three popular databases and compared outcomes of SRS versus surgery for the treatment of multiple meningiomas in patients with NF2. A total of 50 patients (27 radiosurgical and 23 surgical) were identified. For patients treated with SRS, local tumor control was achieved in 22 patients (81.5%) and distal control was achieved in 14 patients (51.8%). No malignant inductions were observed at an average follow-up duration of 90 months. Complications in the SRS-treated cohort were reported in 9 patients (33%). Eight patients (29.6%) died due to disease progression. Six patients experienced treatment failure and required further management. For NF2 patients treated with surgery, 11 patients (48%) showed tumor recurrence and 10 patients (43.5%) died due to neurological complications. SRS may be a safe and effective alternative for NF2-associated meningiomas. Further studies are required to identify the ideal radiosurgical candidate.

Impact of Cochlear Dose on Hearing Preservation following Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy for the Treatment of Vestibular Schwannoma.

Objective The objective of this study was to examine the effect of cochlear dose on hearing preservation in stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) for vestibular schwannoma (VS). Design This is a retrospective case-control study. Setting This study was completed at the Ronald Reagan UCLA Medical Center, a university-affiliated tertiary care center. Participants Patients who underwent SRS (marginal dose of 12 Gy) or fSRT (marginal dose of 50.4 Gy) procedures for VS were included in the study. Main Outcome Measures The main outcome measure was hearing preservation. Audiometric data, when available, were used to determine the level of hearing according to the Gardner Robertson scale. Results A total of 38 patients (14 SRS and 24 fSRT) were analyzed. SRS patients with decreased hearing received a significantly higher minimum cochlear dose (7.41 vs. 4.24 Gy, p = 0.02) as compared with those with stable hearing. In fSRT patients, there were no significant differences in cochlear dose for patients with decreased hearing as compared with those with stable hearing. For SRS patients, who received a minimum cochlear dose above 6 Gy, there was a significant risk of decreased hearing preservation (odds ratio: 32, p = 0.02). Conclusion Higher minimum cochlear dose was predictive of decreased hearing preservation following SRS. Though the study is low powered, the radiation dose to the cochlea should be a parameter that is considered when planning SRS or fSRT therapies for patients with VS.

Dermoid Cyst of the Prepontine Cistern and Meckel's Cave: Illustrative Case and Systematic Review.

Objective Dermoid cysts are benign, congenital malformations that account for ∼0.5% of intracranial neoplasms. The authors describe a 42-year-old female with a prepontine dermoid cyst who underwent apparent gross total resection (GTR) but experienced cyst recurrence. To date, very few cases of prepontine dermoid cysts have been reported. The prevalent region where these cysts are located can be difficult to determine. In addition, the authors systematically review the literature to characterize the clinical presentation, anatomical distribution, and surgical outcomes of intracranial dermoid cysts. Design Systematic review. Setting/Participants PubMed, Web of Science, and Scopus databases. Main Outcome Measures Extent of resection, symptom improvement, and recurrence rates. Results A total of 69 patients with intracranial dermoid cysts were identified. Three (4.3%) intracranial dermoid cysts were located in the prepontine cistern. The average age of patients was 33.3 years. The most common presenting symptoms were headache (52.2%) and visual disturbances (33.3%). Intracranial dermoid cysts were distributed similarly throughout the anterior, middle, and posterior cranial fossae (29.0%, 36.2%, and 29.0%, respectively). GTR was achieved in 42.0% of cases. Thirty-four (49.3%) patients experienced symptom resolution. Recurrence rate was 5.8% at a mean follow-up of 2.1 years. Conclusions Intracranial dermoid cysts most often present as headaches and visual disturbances. Intracranial dermoid cysts were found in the anterior, middle, and posterior cranial fossae at similar frequencies but with clear predilections for the Sylvian fissure, sellar region, and cerebellar vermis. Outcomes following surgical excision of intracranial dermoid cysts are generally favorable despite moderate rates of GTR.

A Systematic Review of Radiosurgery Versus Surgery for Neurofibromatosis Type 2 Vestibular Schwannomas.

OBJECTIVE: Neurofibromatosis type 2 (NF2) is an autosomal dominant disease characterized by bilateral vestibular schwannomas (VSs). NF2-associated VSs (NF2-VSs) are routinely treated with microsurgery; however, stereotactic radiosurgery (SRS) has emerged as an effective alternative in recent decades. To elucidate the role of SRS in NF2-VSs, a systematic review of the literature was conducted to compare outcomes of SRS versus surgery. METHODS: PubMed, Web of Science, Scopus, Embase, and Cochrane databases were queried using relevant search terms. Retrospective studies investigating outcomes of NF2-VS patients treated with either SRS or surgery were included. Single-patient case reports were excluded. Outcome measures between the SRS and surgery groups were compared using χ2 2-sample tests for equality of proportions on the pooled patient data. RESULTS: A total of 974 patients (485 SRS, 489 surgery) were identified. The mean 5-year local control rate for SRS was 75.1%, and the mean recurrence rate for surgery was 8.1%. The mean hearing and facial nerve preservation rates were 40.1% and 92.3%, respectively, for SRS and 52.0% and 75.7%, respectively, for surgery. Rates of hearing preservation were higher after surgery than after SRS (P = 0.006), whereas rates of facial nerve preservation were higher after SRS than after surgery (P < 0.001). CONCLUSIONS: SRS appears to be a safe and effective alternative to surgery for NF2-VS. Although rates of hearing preservation were higher in the surgery cohorts, SRS demonstrated high rates of local control and significantly lower facial nerve complications. Certain patients may therefore benefit more from SRS than surgery.

Tissue microarray analysis for epithelial membrane protein-2 as a novel biomarker for gliomas.

Epithelial membrane protein-2 (EMP2) expression is noted in many human cancers. We evaluated EMP2 as a biomarker in gliomas. A large tissue microarray of lower grade glioma (WHO grades II-III, n = 19 patients) and glioblastoma (GBM) (WHO grade IV, n = 50 patients) was stained for EMP2. EMP2 expression was dichotomized to low or high expression scores and correlated with clinical data. The mean EMP2 expression was 1.68 in lower grade gliomas versus 2.20 in GBMs (P = 0.01). The percentage of samples with high EMP2 expression was greater in GBMs than lower grade gliomas (90.0 vs. 52.6%, P = 0.001). No significant difference was found between median survival among patients with GBM tumors exhibiting high EMP2 expression and survival of those with low EMP2 expression (8.38 vs. 10.98 months, P = 0.39). However, EMP2 expression ≥2 correlated with decreased survival (r = -0.39, P = 0.001). The EMP2 expression level also correlated with Ki-67 positivity (r = 0.34, P = 0.008). The mortality hazard ratio for GBM patients with EMP2 score of 3 or higher was 1.92 (CI 0.69-5.30). Our findings suggest that elevated EMP2 expression is associated with GBM. With other biomarkers, EMP2 may have use as a molecular target for the diagnosis and treatment of gliomas.

Novel Method of Measuring Canal Dehiscence and Evaluation of its Potential as a Predictor of Symptom Outcomes After Middle Fossa Craniotomy.

BACKGROUND: Superior semicircular canal dehiscence (SSCD) is an osseous defect of the arcuate eminence of the petrous temporal bone. Strategies for measuring dehiscence size are variable, and the usefulness of such parameters remains in clinical equipoise. OBJECTIVE: To present a novel method of measuring dehiscence volume and to evaluate its potential as a predictor of symptom outcomes after surgical repair of SSCD. METHODS: High-resolution computed tomographic temporal bone images were imported into a freely available segmentation software. Dehiscence lengths and volumes were ascertained by independent authors. Inter-rater observer reliability was assessed using Cronbach's alpha. Correlation and regression analyses were performed to evaluate for relationships between dehiscence size and symptoms (pre- and post-operative). RESULTS: Thirty-seven dehiscences were segmented using the novel volumetric assessment. Cronbach's alpha for dehiscence lengths and volumes were 0.97 and 0.95, respectively. Dehiscence lengths were more variable as compared to dehiscence volumes (σ2 8.92 vs σ2 0.55, F = 1.74). The mean dehiscence volume was 2.22 mm3 (0.74, 0.64-0.53 mm3). Dehiscence volume and headache at presentation were positively correlated (Rpb = 0.67, P = .03). Dehiscence volume and vertigo improvement after surgery were positively correlated, although this did not reach statistical significance (Rpb = 0.46, P = .21). CONCLUSION: SSCD volumetry is a novel method of measuring dehiscence size that has excellent inter-rater reliability and is less variable compared to dehiscence length, but its potential as a predictor of symptom outcomes is not substantiated. However, the study is limited by low power.

Genomic and Molecular Characterization of Brain Tumors in Asian and Non-Asian Patients of Los Angeles: A Single Institution Analysis.

BACKGROUND: Worldwide, approximately 2% of new cancers are of the brain. Five-year survival rates among brain cancer patients have been reported as a little over a third. Differences in clinical outcomes between brain tumor patients of different races remain poorly understood. METHODS: A retrospective chart review was performed on brain tumor resection patients≥18 years old. Demographics, treatment variables, and survival outcomes were collected. Primary outcomes were length of stay, recurrence rate, progression-free survival (PFS), and overall survival (OS). RESULTS: A total of 452 patients were included in analysis. Females and males had nearly a 1:1 ratio (n=242 and n=220, respectively). Mean age was 54.8 years (SD: 14.5 range: 18-90). Females composed 69% (n=48) of Asian patients; males constituted 31% (n=22). Mean age of the Asian patients was 55.9 years (SD: 14.6 range: 26-89). Asian-only cohort tumor pathologies included glioblastoma (GBM) (n=14), high-grade glioma (n=7), low-grade glioma (n=4), meningioma (n=38), and metastases (n=7). Of the 185 meningioma patients, non-Asian patients comprised 79% of the group (n=146). Of the 65 GBM patients in total, non-Asian patients made up 89% of the GBM cohort (n=58). There were no statistically significant differences between these groups of both cohorts in recurrence (p=0.1580 and p=0.6294, respectively), PFS (p=0.9662 and p=0.4048, respectively), or OS (p=0.3711 and p=0.8183, respectively). CONCLUSION: Studies evaluating the survival between patients of different racial backgrounds against several tumor varieties are rare. Patients of certain racial backgrounds may need additional consideration when being attended to despite the same mutational composition as their counterparts. Repeated studies using national databases may yield more conclusive results.

Fatal Colloid Cysts: A Systematic Review.

OBJECTIVE: To accurately describe patient characteristics and the clinical presentation of fatal colloid cysts. METHODS: A systematic literature search of 3 popular databases was performed. Inclusion criteria were individuals with sudden-onset death and colloid cysts identified on imaging and/or autopsy. The cause of death must have been ascribed to the colloid cyst to be eligible for data extraction. Deaths precipitated by lumbar puncture were excluded. Clinical data were extracted and descriptive statistics were ascertained. Subgroup analyses were performed to compare adults with pediatric patients. RESULTS: A total of 107 patients were included in the quantitative synthesis. The mean age was 28.5 years (standard deviation 13.3, range 6-79 years). Male and female patients were affected equally. Headache was the most frequent symptom (n = 86, 80%). There were 6 patients (5 adults and 1 child) who reported positional headaches. The mean duration of signs and symptoms was shorter in adults versus pediatric patients (2.1 days vs. 6.5 days, P = 0.02), and more adults presented with signs and symptoms for less than 24 hours than did pediatric patients (38% vs. 6%, P = 0.01). Colloid cyst mean diameter was 2.0 cm (standard deviation 1.1, range 0.5-7.9 cm) and 96% measured 1 cm or larger. CONCLUSIONS: Our data suggests that the prodrome preceding sudden death in the setting of a colloid cyst may be shorter in adults. Also, most fatal colloid cysts measured 1 cm or larger.

Epithelial membrane protein 2: Molecular interactions and clinical implications.

Epithelial membrane protein 2 (EMP2) is a cell surface protein that has recently emerged as an object of neuro-oncological interest due to its potential to be utilized as a biomarker and target for antibody therapies. Preclinical studies have demonstrated that EMP2 is associated with disease prognosis in a number of human cancers, including glioblastoma. The four large extracellular domains of EMP2 and its association with the extracellular matrix makes it an attractive target for future cancer therapies. Translational research suggests that EMP2 may be targeted with antibodies to improve tumor control and survival in a variety of murine models and cancer types. However, in order to translate these preclinical findings into the clinic, future research will need to focus on elucidating the role EMP2 in the normal human body by better understanding its molecular and chemical interactions. The focus of this review is to provide a comprehensive insight into current research endeavors, discuss the potential for clinically translatable applications, and predict the future directions of such research.

Early experience with formalin-fixed paraffin-embedded (FFPE) based commercial clinical genomic profiling of gliomas-robust and informative with caveats.

BACKGROUND: Commercial targeted genomic profiling with next generation sequencing using formalin-fixed paraffin embedded (FFPE) tissue has recently entered into clinical use for diagnosis and for the guiding of therapy. However, there is limited independent data regarding the accuracy or robustness of commercial genomic profiling in gliomas. METHODS: As part of patient care, FFPE samples of gliomas from 71 patients were submitted for targeted genomic profiling to one commonly used commercial vendor, Foundation Medicine. Genomic alterations were determined for the following grades or groups of gliomas; Grade I/II, Grade III, primary glioblastomas (GBMs), recurrent primary GBMs, and secondary GBMs. In addition, FFPE samples from the same patients were independently assessed with conventional methods such as immunohistochemistry (IHC), Quantitative real-time PCR (qRT-PCR), or Fluorescence in situ hybridization (FISH) for three genetic alterations: IDH1 mutations, EGFR amplification, and EGFRvIII expression. RESULTS: A total of 100 altered genes were detected by the aforementioned targeted genomic profiling assay. The number of different genomic alterations was significantly different between the five groups of gliomas and consistent with the literature. CDKN2A/B, TP53, and TERT were the most common genomic alterations seen in primary GBMs, whereas IDH1, TP53, and PIK3CA were the most common in secondary GBMs. Targeted genomic profiling demonstrated 92.3%-100% concordance with conventional methods. The targeted genomic profiling report provided an average of 5.5 drugs, and listed an average of 8.4 clinical trials for the 71 glioma patients studied but only a third of the trials were appropriate for glioma patients. CONCLUSIONS: In this limited comparison study, this commercial next generation sequencing based-targeted genomic profiling showed a high concordance rate with conventional methods for the 3 genetic alterations and identified mutations expected for the type of glioma. While it may not be feasible to exhaustively independently validate a commercial genomic profiling assay, examination of a few markers provides some reassurance of its robustness. While potential targeted drugs are recommended based on genetic alterations, to date most targeted therapies have failed in glioblasomas so the usefulness of such recommendations will increase with development of novel and efficacious drugs.

Dural Arteriovenous Fistula and Foix-Alajouanine Syndrome: Assessment of Functional Scores with Review of Pathogenesis.

OBJECTIVE: To assess the use of functional scores in the evaluation of patients with dural arteriovenous fistula and Foix-Alajouanine syndrome. METHODS: We systematically surveyed the literature to identify relevant patients. Aminoff-Logue Scale (ALS) and modified Rankin Scale (mRS) scores were ascertained and combined to form a novel functional score, the Aminoff-Rankin Composite (ARC) score. We compared functional scores between surgery and embolization groups and ran one-sided point-biserial analyses to test our expectation that positive correlations exist between functional scores and treatment outcomes. Finally, we reviewed the pathogenesis of dural arteriovenous fistula formation. RESULTS: The quantitative synthesis included 18 patients. Surgery alone was performed in 11 patients (61.11%); 7 patients underwent embolization alone (38.89%). There were no significant differences in functional scores or symptom outcomes when we compared surgery to embolization. The pre-intervention ALS gait, mRS, and ARC scores were correlated with improved symptoms (rpb = 0.43, P = 0.04; rpb = 0.47, P = 0.02; rpb = 0.48, P = 0.04, respectively). In patients whose symptoms were improved, post-intervention ALS gait and micturition scores (2.55 vs. 4.43, P = 0.02 and 1.09 vs. 2.71, P = 0.01, respectively) and post-intervention ARC scores (6.66 vs. 11.57, P = 0.01) were on average lower than in patients whose symptoms were unimproved. CONCLUSIONS: We believe that patients with dAVF and Foix-Alajouanine syndrome present with worse function (higher functional scores) as a result of an acute myelopathic episode, and that if diagnosed and treated appropriately, will experience some level of symptom improvement that is evidenced by reduced post-intervention functional scores.

A Method of Locating the Dehiscence during Middle Fossa Approach for Superior Semicircular Canal Dehiscence Surgery.

Objectives Superior semicircular canal dehiscence (SSCD) results from a defect in the middle cranial fossa floor. One challenge during SSCD repair is the lack of a consistent landmark. This study proposes a reference point above the external auditory canal at the level of the zygoma as the inferior craniectomy edge during surgery. Design This is a retrospective review of patients with SSCD. Setting/Participants A total of 72 cases of SSCD in 60 patients were repaired via a middle fossa approach at a single institution. Main Outcome Measures The distance from the proposed reference point to the dehiscence was statistically analyzed using Shapiro-Wilk's goodness-of-fit test and Student's t -test. Results Average distance for all patients was 28.84 ± 2.22 mm (range: 22.96-33.43). Average distance for females was 29.08 mm (range: 24.56-33.43) versus 28.26 mm (range: 22.96-32.36) for males. There was no difference in distance by sex ( p = 0.174). The distance measurements followed a normal distribution with 95% of the patients between 24.49 and 33.10 mm. Conclusion This study analyzed a potential reference point during a middle fossa approach for SSCD surgery. The distance from this reference point to the SSCD was found to be consistent and may serve as a readily identifiable landmark in localizing the dehiscence.

Predictors of Outcomes in Fourth Ventricular Epidermoid Cysts: A Case Report and a Review of Literature.

OBJECTIVE: To present an illustrative case of fourth ventricular epidermoid cyst and review the literature to identify predictors of surgical outcomes. METHODS: A case of fourth ventricular epidermoid cyst is presented and a systematic review of 5 popular databases was performed by independent authors. Stepwise logistic regression was performed to identify clinical predictors of outcomes. RESULTS: A 21-year-old woman presented with 3 months of headaches and visual obscurations and was diagnosed with a multilobulated mass in the fourth ventricle. The patient underwent suboccipital craniotomy. Complete removal of the mass was achieved and the final diagnosis was consistent with an epidermoid cyst. The systematic review identified 23 studies that reported 37 patients. Mean age was 42.8 years. Mean length of time between symptom onset and diagnosis was 4.43 years. Age (P = 0.049) and duration of symptoms (P < 0.001) were significantly different between patients who experienced symptom improvement and those who did not. Duration of symptom onset to diagnosis was a significant predictor of poor outcomes (odds ratio, 1.19, 95% confidence interval, 1.003-4.785). CONCLUSIONS: Our review found that in patients with fourth ventricular epidermoid cysts, unfavorable outcomes were predicted by older age and by longer intervals from symptom onset to diagnosis. Clinicians should maintain a high index of suspicion for fourth ventricular epidermoid cysts in patients presenting with cerebellar signs and visual disturbances.

Skull fracture with effacement of the superior sagittal sinus following drone impact: a case report.

BACKGROUND: The popularity of unmanned aerial vehicles, or drones, raises safety concerns as they become increasingly common for commercial, personal, and recreational use. Collisions between drones and people may result in serious injuries. CASE REPORT: A 13-year-old male presented with a comminuted depressed skull fracture causing effacement of the superior sagittal sinus secondary to a racing drone impact. The patient experienced a brief loss of consciousness and reported lower extremity numbness and weakness after the accident. Imaging studies revealed bone fragments crossing the superior sagittal sinus with a short, focal segment of blood flow interruption. Neurosurgical intervention was deferred given the patient's improving neurological deficits, and the patient was treated conservatively. He was discharged home in stable condition. CONCLUSION: Drones may represent a hazard when operated inappropriately due to their capacity to fly at high speeds and altitudes. Impacts from drones can carry enough force to cause skull fractures and significant head injuries. The rising popularity of drones likely translates to an increased incidence of drone-related injuries. Thus, clinicians should be aware of this growing trend.