Factors influencing discharge against medical advice (DAMA) in traumatic brain injury patients requiring decompressive surgery: a comprehensive analysis.

raumatic brain injury (TBI) is a significant global health concern, particularly affecting young individuals, and is a leading cause of mortality and morbidity worldwide. Despite improvements in treatment infrastructure, many TBI patients choose discharge against medical advice (DAMA), often declining necessary surgical interventions. We aimed to investigate the factors that can be associated with DAMA in TBI patients that were recommended to have surgical treatment. This study was conducted at single tertiary university center (2008-2018), by retrospectively reviewing 1510 TBI patients whom visited the emergency room. We analyzed 219 TBI surgical candidates, including 50 declining surgery (refused group) and the others whom agreed and underwent decompressive surgery. Retrospective analysis covered demographic characteristics, medical history, insurance types, laboratory results, CT scan findings, and GCS scores. Statistical analyses identified factors influencing DAMA. Among surgical candidates, 169 underwent surgery, while 50 declined. Age (60.8 ± 17.5 vs. 70.5 ± 13.8 years; p < 0.001), use of anticoagulating medication (p = 0.015), and initial GCS scores (9.0 ± 4.3 vs. 5.3 ± 3.2; p < 0.001) appeared to be associated with refusal of decompressive surgery. Based on our analysis, factors influencing DAMA for decompressive surgery included age, anticoagulant use, and initial GCS scores. Contrary to general expectations and some previous studies, our analysis revealed that the patients' medical conditions had a larger impact than socioeconomic status under the Korean insurance system, which fully covers treatment for TBI. This finding provides new insights into the factors affecting DAMA and could be valuable for future administrative plans involving national insurance.

Proteomic analysis predicts anti-angiogenic resistance in recurred glioblastoma.

BACKGROUND: Recurrence is common in glioblastoma multiforme (GBM) because of the infiltrative, residual cells in the tumor margin. Standard therapy for GBM consists of surgical resection followed by chemotherapy and radiotherapy, but the median survival of GBM patients remains poor (~ 1.5 years). For recurrent GBM, anti-angiogenic treatment is one of the common treatment approaches. However, current anti-angiogenic treatment modalities are not satisfactory because of the resistance to anti-angiogenic agents in some patients. Therefore, we sought to identify novel prognostic biomarkers that can predict the therapeutic response to anti-angiogenic agents in patients with recurrent glioblastoma. METHODS: We selected patients with recurrent GBM who were treated with anti-angiogenic agents and classified them into responders and non-responders to anti-angiogenic therapy. Then, we performed proteomic analysis using liquid-chromatography mass spectrometry (LC-MS) with formalin-fixed paraffin-embedded (FFPE) tissues obtained from surgical specimens. We conducted a gene-ontology (GO) analysis based on protein abundance in the responder and non-responder groups. Based on the LC-MS and GO analysis results, we identified potential predictive biomarkers for anti-angiogenic therapy and validated them in recurrent glioblastoma patients. RESULTS: In the mass spectrometry-based approach, 4957 unique proteins were quantified with high confidence across clinical parameters. Unsupervised clustering analysis highlighted distinct proteomic patterns (n = 269 proteins) between responders and non-responders. The GO term enrichment analysis revealed a cluster of genes related to immune cell-related pathways (e.g., TMEM173, FADD, CD99) in the responder group, whereas the non-responder group had a high expression of genes related to nuclear replisome (POLD) and damaged DNA binding (ERCC2). Immunohistochemistry of these biomarkers showed that the expression levels of TMEM173 and FADD were significantly associated with the overall survival and progression-free survival of patients with recurrent GBM. CONCLUSIONS: The candidate biomarkers identified in our protein analysis may be useful for predicting the clinical response to anti-angiogenic agents in patients with recurred GBM.

Comparison of the efficacy in improving trigeminal neuralgia in petroclival meningioma between microsurgery and radiosurgery: a meta-analysis.

The purpose of this study was to systematically review studies in the literature to assess the superiority between microsurgery and radiosurgery regarding the efficacy in improving petroclival meningioma (PCM)-related trigeminal neuralgia (TN). PubMed, Embase, Web of Science, and Cochrane clinical trial databases were systematically searched from the inception until December 08, 2022. The overall proportion of patients with improved TN after treatment in all six included studies was 56% (95% confidence interval [CI], 35-76.9%). Higgins I2 statistics showed significant heterogeneity (I2 = 90%). Subgroup analysis showed that the proportion of improved TN was higher in the microsurgery group than that in the radiosurgery group (89%; 95% CI, 81-96.5% vs. 37%, 95% CI, 22-52.7%, respectively, p < 0.01). Subgroup analysis (for studies that documented the number of posttreatment Barrow Neurological Institute scores 1 and 2) revealed that the proportion of pain-free without medication after treatment was higher in the microsurgery group than that in the radiosurgery group (90.7%; 95% CI, 81-99.7% vs. 34.5%, 95% CI, 21.3-47.7.7%, respectively, p < 0.01). Based on the results of this meta-analysis, we concluded that microsurgery is superior to radiosurgery in controlling PCM-related TN.

The risk factors of postoperative infarction after surgical clipping of unruptured anterior communicating artery aneurysms: anatomical consideration and infarction territory.

PURPOSE: An anterior communicating artery is a common location for both ruptured and unruptured intracranial aneurysms, and microsurgery is sometimes necessary for their successful treatment. However, postoperative infarction should be considered during clipping due to the complex surrounding structures of anterior communicating artery aneurysms. This study aimed to evaluate the risk factors of postoperative infarction after surgical clipping of unruptured anterior communicating artery aneurysms and its clinical outcomes. METHODS: The data of patients who underwent microsurgical clipping of an unruptured anterior communicating artery aneurysm in our hospital between January 2008 and December 2020 were retrospectively analyzed. The patients' demographic data, anatomical features of the anterior communicating artery complex and aneurysm, surgical technique, characteristics of postoperative infarction, and its clinical course were evaluated. RESULTS: Notably, among 848 patients, 66 (7.8%) and 34 (4%) patients had radiologic and symptomatic infarctions, respectively. Univariate and multivariate logistic regression analyses showed that hypertension (odds ratio (OR), 1.99; [Formula: see text]), previous stroke (OR, 3.89; [Formula: see text]), posterior projection (OR, 5.58; [Formula: see text]), aneurysm size (OR, 1.17; optimal cut-off value, 6.14 mm; [Formula: see text]), and skull base-to-aneurysm distance (OR, 1.15; optimal cut-off value, 11.09 mm; [Formula: see text]) were associated with postoperative infarction. In the pterional approach, a closed A2 plane was an additional risk factor (OR, 1.88; [Formula: see text]). Infarction of the subcallosal and hypothalamic branches was significantly associated with symptomatic infarction ([Formula: see text]). CONCLUSION: Hypertension, previous stroke, posteriorly projecting aneurysms, aneurysm size, and highly positioned aneurysms are independent risk factors for postoperative infarction during surgical clipping of an unruptured anterior communicating artery aneurysm. Additionally, a closed A2 plane is an additional risk factor of postoperative infarction in patients undergoing clipping via the pterional approach.

Reactive Oxygen Species Scavenger in Acute Intracerebral Hemorrhage Patients: A Multicenter, Randomized Controlled Trial.

[Figure: see text].

Growth rate and fate of untreated hemangioblastomas: clinical assessment of the experience of a single institution.

BACKGROUND: The growth rate and natural history of untreated hemangioblastomas remain unclear. This study investigated the natural history of untreated intracranial hemangioblastomas and predictors of tumor growth using volumetric assessment. METHOD: This study retrospectively enrolled 31 patients with untreated hemangioblastomas between 2004 and 2017 who were followed up for at least 12 months. The 31 patients had a total of 52 hemangioblastomas. RESULTS: The 31 patients included 11 (35.5%) men and 20 (64.5%) women, of mean age 42.5 years. Seventeen (54.8%) patients were genetically diagnosed with Von Hippel-Lindau (VHL) disease. Of the 52 lesions, 33 (63.5%) grew during the follow-up period, whereas 19 (36.5%) remained stable. Overall mean actual growth rate (AGR) was 1.94 cm3/year, 2.38 cm3/year in the VHL and 1.79 cm3/year in the non-VHL group (p = 0.31). Overall mean relative growth rate (RGR) was 21%/year, 26%/year in the VHL and 19%/year in the non-VHL group. Time to 50% treatment probability was 34 months. The 1, 3, 5, and 7-year treatment probabilities were 11.5%, 50.1%, 52.7%, and 73%, respectively. The presence of only symptomatic lesions was significantly predictive of the growth of intracranial hemangioblastoma (odds ratio: 5.0, p = 0.02). CONCLUSION: The overall growth rate of intracranial hemangioblastoma was faster than that of other benign intracranial tumors, with symptomatic lesions being the only meaningful predictor of tumor growth. Because of their rapid growth rate and high probability of treatment, a wait and scan management strategy should be carefully applied to intracranial hemangioblastomas.

Prognosis and treatment outcomes of central neurocytomas: clinical interrogation based on a single center experience.

INTRODUCTION: Central neurocytoma (CN) is a very rare neuronal neoplasm. The clinical implications of the potential prognostic factors for these lesions, including tumor atypia, have therefore not been clarified. METHODS: Forty CN patients were enrolled and reclassified as typical or atypical in accordance with an MIB-1 labeling index (LI) of above and below 2%. RESULTS: We classified our retrospective study cohort as 21 (52.5%) typical and 19 (47.5%) atypical CN cases. No significant differences were found in terms of sex, mean age, mean tumor size or tumor location between these groups. Recurrences occurred in 2 (9.5%) typical and 6 (33.3%) atypical cases. The typical CN 2-,3- and 5-year PFS rates were 100%, 100%, 92.3%, and those for the atypical group were 93.8%, 78.1%, 65.1%, respectively (p = 0.02). The PFS rates did not statistically differ by treatment modality (gross total resection alone, subtotal resection (STR) alone and STR plus radiation therapy (RT) or radiosurgery (RS)) either in the whole cohort (p = 0.75) or in the typical CN and atypical CN subgroups (p = 0.45 and 0.98, respectively). An atypical histology was the only prognostic indicator of recurrence by univariate analysis (hazard ratio: 5.40, p = 0.04). CONCLUSIONS: An atypical lesion (MIB-LI > 2%) is an important prognostic indicator in CN. The clinical implications of the extent of resection for CN patients are still debatable. The use of STR plus RT or RS may be a viable treatment strategy for CN but different therapeutic and follow-up approaches for atypical CN will be needed.

Treatment Strategy of Unruptured Intracranial Aneurysms in Octogenarian Patients: A Single-Institution Experience.

AIM: To share our clinical insights into octogenarian patients with unruptured intracranial aneurysms (UIAs) and evaluate the treatment strategies for this demographic. MATERIAL AND METHODS: A retrospective analysis was conducted on data from 134 patients with a follow-up exceeding 6 months, all enrolled in this study. We assessed the incidence rates (IRs) of aneurysm growth and rupture, along with potential predictors of aneurysm growth. RESULTS: Among the 134 patients, 99 (73.9%) underwent conservative management, 25 (18.7%) received coiling, and 10 (7.5%) underwent clipping. The mean age of the cohort was 81.8 years. The middle cerebral artery was the most common location for aneurysms. The mean aneurysm size was 4.9 mm, with sizes significantly larger in the treatment groups (coiling and clipping) compared to the observation group (4.4 mm in the observation group; 5.9 and 7.4 mm in the coiling and clipping groups, respectively). The proportion of aneurysms with a daughter sac was higher in the treatment groups compared to the observation group (6.1% vs. 44% [coiling] and 50% [clipping]). The IR of aneurysm growth was 5.9 per 100 person-years, and that of aneurysm rupture was 0.8 per 100 person-years. No factors were statistically significant for aneurysm growth. CONCLUSION: Age alone, especially in individuals over 80 years old, may not be a contraindication for UIA treatment. We recommend considering treatment in octogenarians with high-risk aneurysm features, such as a large aneurysm and the presence of a daughter sac, as the complication rates are low.

Chemical and perfusion markers as predictors of moyamoya disease progression and complication types.

To investigate the association between chemical markers (triglyceride, C-reactive protein (CRP), and inflammation markers) and perfusion markers (relative cerebral vascular reserve (rCVR)) with moyamoya disease progression and complication types. A total of 314 patients diagnosed with moyamoya disease were included. Triglyceride and CRP levels were assessed and categorized based on Korean guidelines for dyslipidemia and CDC/AHA guidelines, respectively. Perfusion markers were evaluated using Diamox SPECT. Cox proportional hazard analysis was performed to examine the relationship between these markers and disease progression, as well as complication types (ischemic stroke, hemorrhagic stroke, and rCVR deterioration). Elevated triglyceride levels (≥ 200) were significantly associated with higher likelihood of end-point events (HR: 2.292, CI 1.00-4.979, P = 0.03). Severe decreased rCVR findings on Diamox SPECT were also significantly associated with end-point events (HR: 3.431, CI 1.254-9.389, P = 0.02). Increased CRP levels and white blood cell (WBC) count were significantly associated with moyamoya disease progression. For hemorrhagic stroke, higher triglyceride levels were significantly associated with end-point events (HR: 5.180, CI 1.355-19.801, P = 0.02). For ischemic stroke, severe decreased rCVR findings on Diamox SPECT (HR: 5.939, CI 1.616-21.829, P < 0.01) and increased CRP levels (HR: 1.465, CI 1.009-2.127, P = 0.05) were significantly associated with end-point events. Elevated triglyceride, CRP, and inflammation markers, as well as decreased rCVR, are potential predictors of moyamoya disease progression and complication types. Further research is warranted to understand their role in disease pathophysiology and treatment strategies.

Revisiting the Role of Surgical Resection for Brain Metastasis.

Brain metastasis (BM) is the most common type of brain tumor in adults. The contemporary management of BM remains challenging. Advancements in systemic cancer treatment have increased the survival of patients with cancer. Although the treatment of BM is still complicated, advances in radiotherapy, including stereotactic radiosurgery and chemotherapy, have improved treatment outcomes. Surgical resection is the traditional treatment for BM and its role in the surgical resection of BM has been well established. However, refinement of the surgical resection technique and strategy for BM is needed. Herein, we discuss the evolving role of surgery in patients with BM and the future of BM treatment.

A Potential Risk of Radiation-Induced Cavernous Malformations Following Adjuvant Gamma Knife Radiosurgery for Mesial Temporal Lobe Epilepsy.

Objective: Several clinical studies have explored the feasibility and efficacy of radiosurgical treatment for mesial temporal lobe epilepsy, but the long-term safety of this treatment has not been fully characterized. This study aims to report and describe radiation-induced cavernous malformation as a delayed complication of radiosurgery in epilepsy patients. Methods: The series includes 20 patients with mesial temporal lobe epilepsy who underwent Gamma Knife radiosurgery (GKRS). The majority received a prescribed isodose of 24 Gy as an adjuvant treatment after anterior temporal lobectomy. Results: In this series, we identified radiation-induced cavernous malformation in three patients, resulting in a cumulative incidence of 18.4% (95% CI, 6.3 to 47.0%) at an eight-year follow-up. These late sequelae of vascular malformation occurred between 6.9 and 7.6 years after GKRS, manifesting later than other delayed radiation-induced changes, such as radiation necrosis. Neurological symptoms attributed to intracranial hypertension were present in those three cases involving cavernous malformation. Of these, two cases, which initially exhibited an insufficient response to radiosurgery, ultimately demonstrated seizure remission following the successful microsurgical resection of the cavernous malformation. Conclusion: All things considered, the development of radiation-induced cavernous malformation is not uncommon in this population and should be acknowledged as a potential long-term complication. Microsurgical resection of cavernous malformation can be preferentially considered in cases where the initial seizure outcome after GKRS is unsatisfactory.

Middle meningeal artery embolization for chronic subdural hematoma in elderly patients at high risk of surgical treatment.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of middle meningeal artery embolization (MMAE) in elderly high-risk patients with symptomatic chronic subdural hematoma (CSDH) in terms of reduction in hematoma volume and recurrence rate. METHODS: We retrospectively reviewed data prospectively collected from nine patients who underwent 13 MMAE for CSDH between June 2017 and May 2022. The volume of the subdural hematoma was measured using a computer-aided volumetric analysis program. Hematoma volume changes during the follow-up period were analyzed and clinical outcomes were evaluated. RESULTS: The mean follow-up period was 160 days (range, 46-311 days). All procedures were technically successful and there were no procedure-related complications. Of the 13 MMAE, 84% (11 out of 13 hemispheres) showed mean 88% of reduction on follow-up volumetric study with eight cases of complete resolution. There was one refractory case with MMAE which had been performed multiple burr-hole trephinations, for which treatment was completed by craniotomy and meticulous resection of multiple pseudomembranes. There was no recurrent case during the follow-up period, except for refractory case. CONCLUSIONS: MMAE for CSDH in selected high-risk elderly patients and relapsed patients might be effective. Despite the small cohort, our findings showed a high rate of complete resolution with no complications. Further prospective randomized trials are warranted to evaluate its usefulness as a primary treatment option for CSDH.

Pseudoaneurysm formation or dural arteriovenous fistula formation at the middle meningeal artery following revascularization surgery in Moyamoya disease.

Moyamoya disease (MMD) is a rare progressive steno-occlusive cerebrovascular disorder. Currently, revascularization surgery is used as optimal treatment to overcome MMD. However, revascularization for MMD has reported several complications. Also, iatrogenic complications such as pseudoaneurysms formation or dural arteriovenous fistulas (dAVFs) formation-has been identified in rare cases after the surgical intervention for revascularizations. We describe two cases. In first case, the patency of the anastomosis site was good and saccular type pseudoaneurysm formation was found at parietal branch of posterior middle meningeal artery (MMA) in transfemoral cerebral angiography (TFCA) performed on the twelfth day after surgery. We decided to treat pseudoaneurysm by endovascular embolization the next day, but the patient was shown unconsciousness and anisocoria during sleep at that day. Computed tomography showed massive subdural hemorrhage at the ipsilateral side, thus we performed decompressive craniectomy and hematoma evacuation. In second case, the patency of the anastomosis site was good and dAVF formation at right MMA was found in TFCA performed on the sixth day after surgery. We performed endovascular obliteration of the arteriovenous fistula under local anesthesia. Pseudoaneurysm formation or dAVF formation after revascularization surgery is an exceptional case. If patients have such complications, practioner should carefully screen the patients by implementing digital subtraction angiogram to identify anatomic features; as well as consider immediate treatment in any way, including embolization or other surgery.

Antibiotics Prophylaxis for Endoscopic Endonasal Approach for Skull Base Tumor Surgery: A Meta-Analysis.

BACKGROUND: The regimen of prophylactic antibiotic for endoscopic endonasal skull base surgery (EE-SBS) varies considerably depending on surgeons and their institutes. The purpose of the present meta-analysis is to assess the effect of antibiotic regimens on EE-SBS surgery for anterior skull base tumor. METHODS: The PubMed, Embase, Web of Science, and Cochrane clinical trial databases were systematically searched through October 15, 2022. RESULTS: The 20 included studies were all retrospective. The studies included a total of 10,735 patients who underwent EE-SBS for skull base tumor. The proportion of patients with postoperative intracranial infection across all 20 studies was 0.9% (95% confidence interval [CI] 0.5%-1.3%). The proportion of postoperative intracranial infection in the multiple antibiotics group did not show statistically significant difference to that of the single antibiotic agent group (proportion: 0.6%, 95% CI 0%-1.4% vs. proportion: 1%, 95% CI 0.6%-1.5%, respectively, P = 0.39). The ultra-short duration maintenance group showed lower incidence of postoperative intracranial infection, although it did not reach statistical significance (ultra-short group: 0.7%, 95% CI 0.5%-0.9%; short duration: 1.8%, 95% CI 0.5%-3%; and long duration: 1%, 95% CI 0.2%-1.9%, P = 0.22) The combination of the multiple antibiotics group did not show meaningful low incidence of postoperative intracranial infection (antibiotics combination group: 0.6%, 95% CI 0%-1.4%; cefazolin single group: 0.8%, 95% CI 0%-1.6%; and single antibiotics other than cefazolin: 1.2%, 95% CI 0.7%-1.7%, P = 0.22). CONCLUSIONS: Multiple antibiotics did not show superiority compared with single antibiotic agent. Also, long maintenance duration of antibiotics did not reduce the incidence of postoperative intracranial infection.

Predictor of the Postoperative Swelling After Craniotomy for Spontaneous Intracerebral Hemorrhage: Sphericity Index as a Novel Parameter.

Objective: Spontaneous intracerebral hemorrhage is a serious type of stroke with high mortality and disability rates. Surgical treatment options vary; however, predicting edema aggravation is crucial when choosing the optimal approach. We propose using the sphericity index, a measure of roundness, to predict the aggravation of edema and guide surgical decisions. Methods: We analyzed 56 cases of craniotomy and hematoma evacuation to investigate the correlation between the sphericity index and patient outcomes, including the need for salvage decompressive craniectomy (DC). Results: The patients included 35 (62.5%) men and 21 (37.5%) women, with a median age of 62.5 years. The basal ganglia was the most common location of hemorrhage (50.0%). The mean hematoma volume was 86.3 cc, with 10 (17.9%) instances of hematoma expansion. Cerebral herniation was observed in 44 (78.6%) patients, intraventricular hemorrhage in 34 (60.7%), and spot signs in 9 (16.1%). Salvage DC was performed in 13 (23.6%) patients to relieve intracranial pressure. The median follow-up duration was 6 months, with a mortality rate of 12.5%. The sphericity index was significantly correlated with delayed swelling and hematoma expansion but not salvage DC. Conclusions: The sphericity index is a promising predictor of delayed swelling and hematoma expansion that may aid in the development of surgical guidelines and medication strategies. Further large-scale studies are required to explore these aspects and establish comprehensive guidelines.

Treatment Outcome of Gamma Knife Radiosurgery for Brain Metastasis from Thyroid Cancer: Favorable Local Control but Poor Survival.

BACKGROUND: Brain metastasis from thyroid cancer (TCBM) is extremely rare; thus, despite a good treatment outcome for thyroid cancer, TCBM has shown poor clinical outcomes. Considering the short survival and poor general condition of patients with TCBM, stereotactic radiosurgery may be preferred to achieve local control. METHODS: A total of 25 patients with TCBM who underwent Gamma Knife radiosurgery (GKS) were initially included in this study; however, 3 patients were excluded because of a lack of data. RESULTS: There were 7 men (31.8%) and 15 women (68.2%) and the mean age was 63.7 years. The most common type of thyroid cancer histology was papillary carcinoma. Fourteen patients (63.6%) harbored single brain metastatic tumor and 8 (36.3%) had multiple brain metastatic tumors. The mean duration from thyroid cancer diagnosis to detection of brain metastasis was 7.7 years (range, 0-23 years). The median dose of radiation of GKS was 22 Gy (range, 18-25 Gy). There was no radiation-induced complication after GKS. The median overall survival (OS) was 15 months and the 1-year OS of patients with TCBM was 63%, the 2-year OS was 38%, and the 5-year OS was 28%. The 6-month progression-free survival (PFS) for local recurrence of TCBM was 90.4%, the 1-year PFS was 84%, and the 3-year PFS was 84%. CONCLUSIONS: GKS showed favorable local control for TCBM. However, the rate of distant brain metastasis was high and median survival of patients with TCBM was only 15 months.

Necessity of mandatory postoperative intensive care unit management after clipping surgery for unruptured intracranial aneurysms.

OBJECTIVE: Many neurosurgeons routinely perform postoperative intensive care unit (ICU) management after clipping of unruptured intracranial aneurysms (UIAs). However, whether routine postoperative ICU care is necessary remains a clinical question. Therefore, we investigated which factors acted as risk factors that actually required ICU care after microsurgical clipping of unruptured aneurysms. METHODS: We included a total of 532 patients who underwent clipping surgery for UIA between January 2020 and December 2020. The patients were divided into two groups: those who really required ICU care (41 patients, 7.7%) and those who did not (491 patients, 92.3%). A backward stepwise logistic regression model was used to identify factors that were independently associated with ICU care requirement. RESULTS: The mean hospital stay duration and the operation time were significantly longer in the ICU requirement group than in the no ICU requirement group (9.9 ± 10.7 vs. 6.3 ± 3.7 days, p = 0.041), (259.9 ± 128.4 vs. 210.5 ± 46.1 min, p = 0.019). The transfusion rate was significantly higher (p = 0.024) in the ICU requirement group. Multivariable logistic regression analysis identified male sex (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.15-4.76; p = 0.0195), operation time (OR, 1.01; 95% CI, 1.00-1.01; p = 0.0022), and transfusion (OR, 2.35; 95% CI, 1.00-5.51; p = 0.0500) as independent risk factors for requiring ICU care after clipping. CONCLUSIONS: Postoperative ICU management may not be mandatory after clipping surgery for UIAs. Our results suggest that postoperative ICU management may be more required in the male sex, patients with longer operation times, and those who received a transfusion.

Extraventricular Neurocytoma: Clinical Investigation of Heterogenous Prognosis.

BACKGROUND: Extraventricular neurocytoma (EVN) is an extremely rare neuronal neoplasm that arises outside the ventricle. The clinical implication of the heterogenous prognosis of this rare tumor has not yet been clarified. Herein, we analyzed our institutional series of EVN. METHODS: A total of eight consecutive cases were enrolled and investigated. The prognosis of EVN was analyzed and compared to that of central neurocytoma (CN). RESULTS: There were two male and six female patients, and the median age was 36.5 years. The median tumor size was 38 mm, and the most common location of the tumor was the frontal lobe (3, 37.5%), followed by the parietal and temporal lobes. In brain imaging, four (50%) tumors showed peritumoral edema and three (37.5%) tumors showed calcification. All patients underwent gross total resection, and two (25%) underwent adjuvant radiotherapy. The 5-year overall survival (OS) was 55.6%, and the 2-year progression-free survival (PFS) was 42.9%. The OS and PFS of EVN were poor compared to those of CN. Although EVN is a single disease entity, individual patients showed varying prognosis. One patient showed no recurrence during the 7-year follow-up period; however, another patient had a recurrence 4 months after surgery and died 2 years later. CONCLUSION: EVN may be a heterogenous disease entity. Additional cases with long-term followup are needed to develop optimal management protocols.

Fate of Residual Tumor After Subtotal Resection of a Previously Irradiated Vestibular Schwannoma: Long-Term Follow-Up of a Single-Institutional Series.

BACKGROUND: The fate of residual tumor after salvage surgery for recurrent vestibular schwannoma (VS) after radiosurgery has not been elucidated so far. We reviewed our surgical series of salvage surgery for recurrent VS, with focus on the natural history of the residual tumor after salvage surgery. METHODS: This study enrolled 14 patients who underwent salvage surgical resection in our institute and were followed up for >12 months. RESULTS: The study included 3 men and 11 women with a median age of 55 years (range: 16-70 years). The median pre-stereotactic radiosurgery tumor volume was 6591 mm3. All patients were treated using gamma knife radiosurgery. The median duration from gamma knife radiosurgery to surgery was 52 months (range: 10-116 months). Solid tumor growth and cyst formation were observed in 6 (42.9%) and 8 (57.1%) patients, respectively. Subtotal resection and partial resection were performed in 13 (92.8%) patients, and gross total resection was achieved in only one (7.2%) patient. Postoperative facial paresis and surgical complication occurred in 5 (35.7%) and 2 (14.3%) patients, respectively. After salvage resection for irradiated VS, no patient showed tumor progression or recurrence during the follow-up period (13 subtotal/partial resections and 1 total resection). In addition, 2 patients in the subtotal resection group showed residual tumor shrinkage after salvage surgery during the follow-up period. CONCLUSIONS: The behavior of residual tumors after salvage surgery for irradiated VS was stable. Adjuvant treatment for these residual tumors may not be necessary.

Management of Internal Carotid Artery Injury During Transsphenoidal Surgery: A Case Series and Suggestion for Optimal Management.

OBJECTIVE: Internal carotid artery (ICA) injury during transsphenoidal surgery is a rare but serious complication. We analyzed a series of ICA injuries that occurred during a transsphenoidal approach to suggest an optimal management strategy. METHODS: Between January 2015 and May 2020, we enrolled 10 cases of ICA injury at our institution. RESULTS: Among the 10 patients enrolled, 5 had pituitary adenoma, 2 had craniopharyngioma, and 1 each had skull base chondrosarcoma, tuberculum sellae meningioma, and nasopharyngeal cancer; 4 were revision surgery cases. The cavernous segment of the ICA was the most commonly injured area. The most common reason for ICA injury was a drill injury at the sellar floor opening. A direct repair was performed using a clip in only 1 patient. In the others, bleeding control of the injured ICA was achieved by packing multiple cotton pads. After angiography, 6 patients underwent immediate endovascular sacrifice of the injured ICA. In 3 patients who showed poor collateral flow from the anterior communicating and posterior communicating arteries, revascularization surgery was performed before endovascular trapping. After 6 postoperative months, 6 patients showed favorable functional outcomes, and 4 patients showed poor functional outcomes. CONCLUSIONS: Prompt control of bleeding, endovascular management of injured ICA, and consideration of revascularization surgery based on collateral flow may prevent catastrophic neurological sequelae.