Deep brain stimulation of the cerebellum for poststroke motor rehabilitation: from laboratory to clinical trial.

Ischemic stroke is a leading cause of disability worldwide, with profound economic costs. Poststroke motor impairment is the most commonly encountered deficit resulting in significant disability and is the primary driver of stroke-associated healthcare expenditures. Although many patients derive some degree of benefit from physical rehabilitation, a significant proportion continue to suffer from persistent motor impairment. Noninvasive brain stimulation, vagal nerve stimulation, epidural cortical stimulation, and deep brain stimulation (DBS) have all been studied as potential modalities to improve upon the benefits derived from physical therapy alone. These neuromodulatory therapies aim primarily to augment neuroplasticity and drive functional reorganization of the surviving perilesional cortex. The authors have proposed a novel and emerging therapeutic approach based on cerebellar DBS targeted at the dentate nucleus. Their rationale is based on the extensive reciprocal connectivity between the dentate nucleus and wide swaths of cerebral cortex via the dentatothalamocortical and corticopontocerebellar tracts, as well as the known limitations to motor rehabilitation imposed by crossed cerebellar diaschisis. Preclinical studies in rodent models of ischemic stroke have shown that cerebellar DBS promotes functional recovery in a frequency-dependent manner, with the most substantial benefits of the therapy noted at 30-Hz stimulation. The improvements in motor function are paralleled by increased expression of markers of synaptic plasticity, synaptogenesis, and neurogenesis in the perilesional cortex. Given the findings of preclinical studies, a first-in-human trial, Electrical Stimulation of the Dentate Nucleus Area (EDEN) for Improvement of Upper Extremity Hemiparesis Due to Ischemic Stroke: A Safety and Feasibility Study, commenced in 2016. Although the existing preclinical evidence is promising, the results of this Phase I trial and subsequent clinical trials will be necessary to determine the future applicability of this therapy.

Resection of posterior clinoid meningioma through retrosigmoid approach: concepts and nuances.

Meningiomas arising from the posterior clinoid process pose a great surgical challenge because of their location and propensity to cause critical neurovascular compression. The authors' patient was a 66-year-old female who had a large posterior clinoid meningioma with significant brainstem compression that was operated on through the retrosigmoid approach. This 3D surgical video emphasizes the various technical concepts that are important to preserving compressed neural and vascular structures during the surgery. It would also be interesting to note the extent of visualization around the posterior clinoid region gained through a retrosigmoid corridor. The video can be found here: https://youtu.be/CBmT_0ov0YA .

Do the clinicoradiological outcomes of endoscopic fenestration for intracranial cysts count on age? An institutional experience.

BACKGROUND: The clinicoradiological outcome of endoscopic fenestration of intracranial cysts and predictors of an unfavorable outcome, including age, are under reported in the neurosurgical literature. In this cohort, our experience in the endoscopic fenestration of intracranial cysts is reviewed. MATERIALS AND METHODS: Thirty consecutive patients treated with endoscopic fenestration for intracranial cysts were identified and analyzed. The study population in our series was followed clinically and radiographically. RESULTS: In this series, the overall resolution of clinical symptoms such as headache, seizures, and neurological deficits was 83%, P= 0.0001. The percentage of clinical resolution after endoscopic intervention was significantly higher (85% vs. 76%, P= 0.001) in arachnoid cysts compared to other cyst types. The reduction of arachnoid cyst size was significantly higher in adults with obstructive hydrocephalus compared to the children group (P = 0.037). In addition, requirement of a cystoperitoneal shunt placement (P = 0.0001) and its subsequent revision (P = 0.0001) was significantly lower in adults compared to children. Adults (P = 0.041), presence of an arachnoid cyst (P = 0.026), female gender (P = 0.016), and presence of communicative hydrocephalus (P = 0.015) were significant predictors for improvement in the symptoms of intracranial pressure. Lastly, adults (P = 0.028), presence of arachnoid cyst (P = 0.046), and presence of communicative hydrocephalus (P = 0.012) were significant positive predictors for shunt revision. CONCLUSIONS: This study revealed that endoscopic fenestration is an effective neurosurgical procedure for the management of intracranial cysts both in adults and children. Moreover, endoscopic fenestration is more beneficial in adults and patients with an arachnoid cyst compared to that in children and other cyst types, respectively.

Epidemiology of adult-onset hydrocephalus: institutional experience with 2001 patients.

OBJECTIVE Adult-onset hydrocephalus is not commonly discussed in the literature, especially regarding its demographic distribution. In contrast to pediatric hydrocephalus, which is related to a primary CSF pathway defect, its development in adults is often secondary to other pathologies. In this study, the authors investigated the epidemiology of adult-onset hydrocephalus as it pertains to different etiologies and in reference to age, sex, and race distributions. METHODS The authors retrospectively reviewed the clinical notes of 2001 patients with adult-onset hydrocephalus who presented to Louisiana State University Health Sciences Center within a 25-year span. Significant differences between the groups were analyzed by a chi-square test; p < 0.05 was considered significant. RESULTS The overall mean (± SEM) incidence of adult hydrocephalus in this population was 77 ± 30 per year, with a significant increase in incidence in the past decade (55 ± 3 [1990-2003] vs 102 ± 6 [2004-2015]; p < 0.0001). Hydrocephalus in a majority of the patients had a vascular etiology (45.5%) or was a result of a tumor (30.2%). The incidence of hydrocephalus in different age groups varied according to various pathologies. The incidence was significantly higher in males with normal-pressure hydrocephalus (p = 0.03) or head injury (p = 0.01) and higher in females with pseudotumor cerebri (p < 0.0001). In addition, the overall incidence of hydrocephalus was significantly higher in Caucasian patients (p = 0.0002) than in those of any other race. CONCLUSIONS Knowledge of the demographic variations in adult-onset hydrocephalus is helpful in achieving better risk stratification and better managing the disease in patients. For general applicability, these results should be validated in a large-scale meta-analysis based on a national population database.

Spinal meningiomas: clinicoradiological factors predicting recurrence and functional outcome.

OBJECTIVE Spinal meningiomas are benign tumors with a wide spectrum of clinical and radiological features at presentation. The authors analyzed multiple clinicoradiological factors to predict recurrence and functional outcome in a cohort with a mean follow-up of more than 4 years. The authors also discuss the results of clinical studies regarding spinal meningiomas in the last 15 years. METHODS The authors retrospectively reviewed the clinical and radiological details of patients who underwent surgery for spinal tumors between 2001 and 2015 that were histopathologically confirmed as meningiomas. Demographic parameters, such as age, sex, race, and association with neurofibromatosis Type 2, were considered. Radiological parameters, such as tumor size, signal changes of spinal cord, spinal level, number of levels, location of tumor attachment, shape of tumor, and presence of dural tail/calcification, were noted. These factors were analyzed to predict recurrence and functional outcome. Furthermore, a pooled analysis was performed from 13 reports of spinal meningiomas in the last 15 years. RESULTS A total of 38 patients were included in this study. Male sex and tumors with radiological evidence of a dural tail were associated with an increased risk of recurrence at a mean follow-up of 51.2 months. Ventral or ventrolateral location, large tumors, T2 cord signal changes, and poor preoperative functional status were associated with poor functional outcome at 1-year follow-up. CONCLUSIONS Spine surgeons must be aware of the natural history and risk factors of spinal meningiomas to establish a prognosis for their patients.

Role of radiological parameters in predicting overall shunt outcome after ventriculoperitoneal shunt insertion in pediatric patients with obstructive hydrocephalus.

OBJECTIVE Despite significant advances in the medical field and shunt technology, shunt malfunction remains a nightmare of pediatric neurosurgeons. In this setting, the ability to preoperatively predict the probability of shunt malfunction is quite compelling. The authors have compared the preoperative radiological findings in obstructive hydrocephalus and the subsequent clinical course of the patient to determine any association with overall shunt outcome. METHODS This retrospective study included all pediatric patients (age < 18 years) who had undergone ventriculoperitoneal shunt insertion for obstructive hydrocephalus. Linear measurements were taken from pre- and postoperative CT or MRI studies to calculate different indices and ratios including Evans' index, frontal horn index (FHI), occipital horn index (OHI), frontooccipital horn ratio (FOHR), and frontooccipital horn index ratio (FOIR). Other morphological features such as bi- or triventriculomegaly, right-left ventricular symmetry, and periventricular lucency (PVL) were also noted. The primary clinical outcomes that were reviewed included the need for shunt revision, time interval to first shunt revision, frequency of shunt revisions, and revision-free survival. RESULTS A total of 121 patients were eligible for the analysis. Nearly half of the patients (47.9%) required shunt revision. The presence of PVL was associated with lower revision rates than those in others (39.4% vs 58.2%, p = 0.03). None of the preoperative radiological indices or ratios showed any correlation with shunt revision. Nearly half of the patients with shunt revision required early revision (< 90 days of primary surgery). The reduction in the FOHR was high in patients who required early shunt revision (20.16% in patients with early shunt revision vs 6.4% in patients with late shunt revision, p = 0.009). Nearly half of the patients (48.3%) requiring shunt revision ultimately needed more than one revision procedure. Greater occipital horn dilation on preoperative images was associated with a lower frequency of shunt revision, as dictated by a high OHI and a low FOIR in patients with a single shunt revision as compared with those in patients who required multiple shunt revisions (p = 0.029 and 0.009, respectively). The mean follow-up was 49.9 months. Age was a significant factor affecting shunt revision-free survival. Patients younger than 6 months of age had significantly less revision-free survival than the patients older than 6 months (median survival of 10.1 vs 94.1 months, p = 0.004). CONCLUSIONS Preoperative radiological linear indices and ratios do not predict the likelihood of subsequent shunt malfunction. However, patients who required early shunt revision tended to have greater reductions in ventricular volumes on postoperative images. Therefore a greater reduction in ventricular volume is not actually desirable, and a ventricular volume high enough to reduce intracranial pressure is instead to be aimed at for long-term shunt compliance.

Rosai-Dorfman disease presenting as cervical extradural lesion: a case report with review of literature.

Sinus histiocytosis with massive lymphadenopathy or Rosai-Dorfman disease is a rare, but well documented entity. We report a lady who presented with progressive quadriparesis, with cervical extradural lesion on magnetic resonance imaging. She underwent decompression of the lesion and histological diagnosis of the lesion was Rosai-Dorfman disease. On one-year follow-up, she had complete improvement of the deficits with no further progression of the lesion. The presentation of this disease as an isolated spinal extradural mass lesion is quite rare, with only six cases reported in literature.

Teratoma in split cord malformation: an unusual association: a report of two cases with a review of the literature.

Split cord malformations (SCM) may be discovered as isolated occult spinal dysraphism or in association with various other overt developmental spinal abnormalities or lesions. However, the occurrence of SCM with intraspinal teratoma is rare. We report 2 cases of teratoma associated with SCM, of which one is intramedullary and the other extradural within meningocele, with a brief review of the literature.

Foramen magnum meningiomas.

The foramen magnum meningioma (FMM) is one of most challenging tumors among all the meningiomas because of its distinctive location, clinical course, insidious onset, and the relative large size of the tumor during presentation. These tumors are slow-growing and clinical symptoms vary according to involvement of different structures including the spinal cord, vertebral artery, lower cranial nerves, and medulla oblongata. Controversies regarding appropriate surgical approach for resection of tumor in this unique location continue. Tumors in the posterior or posterolateral region of the foramen magnum is accessible by midline suboccipital approach. The anterior and anterolateral tumors are encountered by various modifications of the far lateral approach. Drilling of condylar fossa is adequate in most of the cases as tumors often create a surgical corridor. However, an anterior tumor with significant extension on both sides of midline may require variable amounts of condyle resection. Here we review the FMMs with an emphasis on surgical approaches.

Metal Hypersensitivity After Spinal Instrumentation: When to Suspect and How to Treat.

BACKGROUND: Metal hypersensitivity is a rare complication after spinal implant placement but is related to significant clinical challenges including implant failure and poor wound healing. The incidence is likely underreported secondary to challenges with diagnosis and retreatment options. CASE DESCRIPTION: We present the case of a 41-year-old woman with metal hypersensitivity 6 years status post anterior lumbar interbody fusion after a previously failed revision procedure who presented with low back pain and abdominal pain with food intolerance. Diagnostics revealed presacral fluid collection, which was negative for infection. A detailed workup ruled out other possible differential diagnoses and confirmed hypersensitivity to nickel. Intraoperatively, the interbody was loose but difficult to remove secondary to scar tissue. Ultimately, it was successfully replaced with a polyetheretherketone interbody, which did not contain nickel. CONCLUSIONS: Metal hypersensitivity is likely an underreported complication in spine literature that is associated with poor outcomes. Further research to create evidence-based guidelines on diagnosis and retreatment options will facilitate diagnosis, reduce time to revision surgery, and ultimately decrease patient suffering.

Surgical Outcomes with Midline versus Lateral Approaches for Cranial Base Chordomas: A Systematic Review and Meta-Analysis.

BACKGROUND: Cranial base chordomas are complex lesions centered on the clivus that surgically can be approached from either a midline or a lateral corridor. OBJECTIVE: To compare the surgical outcomes from midline versus lateral approaches by conducting a meta-analysis of the literature. METHODS: Studies were identified between 2000 and 2018. The primary outcome was gross total resection (GTR) rate. The secondary outcomes were recurrence rate and rates of cerebrospinal fluid (CSF) leak and new cranial nerve palsy. Odds ratios were calculated with a random-effect model using studies describing both approaches. An indirect (proportion) meta-analysis was performed pooling studies describing either of the approaches. Individual patient data were analyzed for differences in GTR or recurrence rate with different tumor extensions. RESULTS: Thirty-three studies were found suitable for indirect meta-analysis and 10 studies for direct meta-analysis. The overall odds of GTR with a midline approach compared with a lateral approach was 0.83 (95% confidence interval [CI], -0.43 to 1.62). The odds ratios for recurrence, CSF leak, and new cranial nerve palsy were 0.82 (95% CI, 0.26-2.56), 1.49 (95% CI, 0.14-15.5), and 0.14 (95% CI, 0.04-0.56), respectively. With individual patient data analysis, no statistically significant difference was observed in GTR or recurrence rates between the 2 approaches with different tumor extensions. CONCLUSIONS: The meta-analysis did not show any significant difference in GTR or recurrence rates between the midline versus lateral approaches. Tumor extension to different compartments did not affect the GTR or recurrence rates with either approach. In terms of complications, CSF leak rate was higher in midline approaches and cranial nerve palsy was higher in lateral approaches.

The Relationship Between Obstructive Sleep Apnea and Ruptured Intracranial Aneurysms.

STUDY OBJECTIVES: The role of obstructive sleep apnea (OSA) in the overall outcome of ruptured intracranial aneurysms (RIAs) is unknown. We have investigated the role of OSA in overall outcome of RIAs. METHODS: Data from 159 consecutive patients were retrospectively reviewed. A chi-square test and regression analysis were performed to determine the significant difference. A value of P < .05 was considered significant. RESULTS: The prevalence of OSA in RIAs was fivefold higher in the nonaneurysm patient group, P = .002. The number of patients with hypertension (P < .0001), body mass index ≥ 30 (P < .0001), hyperlipidemia (P = .018), chronic heart disease (P = .002) or prior ischemic stroke (P = .001) was significantly higher in the OSA group. Similarly, the number of wide-neck aneurysms (P < .0001) and aneurysm > 7 mm (P = .004), poor Hunt and Hess grade IV-V (P = .005), vasospasms, (P = .03), and patients with poor Modified Rankin Scale scores (3-6) was significantly higher in the OSA group (P < .0001). Interestingly, for the first time in univariate (P = .01) and multivariate (P = .003) regression analysis, OSA was identified as an individual predictor of unfavorable outcome of RIAs. In addition, hypertension (P = .04), smoking (P = .049), chronic heart disease (P = .01), and Hunt and Hess grade IV-V (P = .04) were revealed as predictors of poor outcome of RIAs. CONCLUSIONS: This is a novel study to determine the association between OSA and ruptured cerebral aneurysm in terms of comorbidities, size of aneurysm, severity of symptoms, and outcomes after treatment. In addition, for the first time, OSA is identified as a positive predictor of unfavorable outcome of RIAs.

Management of a complex intracranial arteriovenous malformation with gamma knife radiosurgery: A case report with review of literature.

The risks and benefits of arteriovenous malformation (AVM) treatment should be considered cautiously in each patient since management strategy of it depends on various factors including age of the patient, location and volume of AVM and presence of other vascular abnormalities. Current management options of AVM include observation, endovascular embolization, radiosurgery and microsurgical resection or in combination of any two of the above procedures. Here, we have discussed a case of intracranial AVM with radiation induced early cyst formation, and performed a literature review to determine the optimum treatment of complex intracranial AVM. Standard search strategies were performed in PubMed/Medline using appropriate terms such as "intracranial arteriovenous malformation" radiosurgery, embolization and microsurgical resection as well as medical subject headings. The particular case in this study was retrospectively reviewed. Literature review revealed that the mean marginal radiation dose used by the different authors was 19 Gy, cysts were developed in 3.6% patients, the average time to form cyst was 6.6 years, average volume of cyst was 6.7 ml and maximum cysts were removed by resection. In our case, the cyst was developed 2.5 years after radiosurgery. Radiation induced cyst formation is a delayed complication of AVM management. However, cyst formation in this case was comparatively earlier in our case. Therefore, continuous follow-up after radiosurgery is required for early detection of cyst formation. In addition, the review revealed that embolization before radiosurgery was a poor strategy.

Tentorial Meningiomas: Reappraisal of Surgical Approaches and Their Outcomes.

BACKGROUND: Tentorial meningiomas are notorious for their critical location. Selection of a suitable approach that exposes the multicompartmental growth of tumor is important for a complete and safe resection. This paper discusses about various operative approaches and their overall surgical outcome. METHODS: We retrospectively reviewed our 41 patients with tentorial meningiomas. They were classified according to the modified Yasargil classification. The symptomatic improvement and progression-free survival (PFS) were analyzed at follow-up. RESULTS: Tumors were almost equally distributed in all location groups. Tumors along the lateral tentorial hiatus were operated on via a subtemporal or transsylvian approach. Tumors along the posterior tentorial hiatus, tentorial membrane, or torcula were operated on by an occipital interhemispheric transtentorial, infratentorial supracerebellar, or a combined approach. Tumors along the petrous attachment were operated on by a retromastoid suboccipital or a combined presigmoid-retrosigmoid approach. Seventy-six percent had total excision (Simpson grade 1 and 2). Group II tumors had the highest total resection rate (100%). Headache and diplopia were the symptoms that significantly improved postoperatively. Over a median follow-up of 65 months, 13 patients (31.7%) had recurrence. There was no significant difference in recurrence rates and PFS in tumors at different locations. Extent of excision and tumor grade were the significant factors affecting PFS in both univariate and multivariate analysis (P = 0.01 and 0.03, respectively). CONCLUSIONS: Similar to intracranial meningiomas at other locations, extent of resection and tumor grade significantly affect the PFS for tentorial meningiomas. Careful preoperative planning based on the location and extension of the tumor guides the optimal surgical approach that translates into maximal safe resection.

Spinal subarachnoid hemorrhage and aneurysms.

Spinal subarachnoid hemorrhage (SAH) is a rare disease. Spinal aneurysms are even rarer and mostly undetected unless they rupture and become symptomatic. In this chapter we aim to review the available literature about spinal subarachnoid hematoma with special emphasis on spinal aneurysms. As most reports of spinal aneurysms describe a single case or a small case series, the diagnostic algorithm is often lacking. The outcome is also different based on the etiologies; therefore management strategy must be individualized. We addressed these issues in this chapter. The reported incidence of spinal SAH is less than epidural hematoma and more than subdural hematoma. Spinal aneurysms can present as isolated entity or can be associated with other vascular anomalies. Microsurgical clipping and/or resection is possible, especially when they are located dorsally or dorsolaterally. Endovascular approach is also a feasible option unless negotiation of microcatheter becomes difficult in tortuous small-caliber arteries. Successful obliteration leads to good outcome, especially when present in posterior spinal artery. A detailed knowledge of spinal SAH and spinal aneurysms is important to detect them in time. Clinicians must consider several factors to choose an appropriate treatment strategy to ensure the safety of their patients.

Spinal cordectomy: A new hope for morbid spinal conditions.

A spinal cordectomy is a treatment option for several disorders of the spinal cord like post-traumatic syringomyelia, spinal cord tumor and myelomeningocele. We have done a systematic analysis of all reported cases of spinal cordectomy to investigate the possible outcomes and complications. A PubMed search was performed for literature published from 1949 to 2015 with search words "spinal cordectomy", "spinal cord transection" and "cordectomy for malignant spinal cord tumors" to select articles containing information about the indication, outcome and complication of spinal cordectomy performed for diverse etiologies. Spinal cordectomy was performed for post-traumatic syrinx (76 cases), SPAM (2 cases), Central pain of spinal cord origin (22 cases), Spasticity (8 cases), Spinal tumors (16 cases) and Myelomeningocele (30 cases). Among the 76 cases, 60 cases fulfilled the inclusion criteria for our outcome analysis in terms of improvement, stabilization or deterioration after spinal cordectomy. The results showed 78.3% excellent improvement, 13.4% stable and 8.3% (5 cases) deterioration. The reported causes of failure of spinal cordectomy for post-traumatic syrinx were scarring of a proximal stump and severe arachnoid adhesion. Sixteen cases of spinal cordectomy related with spinal cord tumors have been reported. Also reported were seven cases of GBM, two cases of AA and one each case of anaplastic tanycytic ependymoma, schwanoma, neurofibroma, atypical meningioma and malignant ganglioglioma. Cordectomy shouldbe strongly considered in patients having malignant spinal cord tumors with complete motor loss and sensory loss below the level of the lesion as a means of preventing the spread of disease from the original tumor focus. Spinal cordectomy is a treatment option with a good outcome for post-traumatic spinal morbidity, spinal cord tumors and myelomeningocele. However, since it is an invasive and irreversible procedure, it is only considered when other options have been exhausted.

A systematic review of overall survival in pediatric primary glioblastoma multiforme of the spinal cord.

OBJECTIVE The incidence of primary spinal cord glioblastoma multiforme (GBM) in the pediatric age group is very rare. Only a few case series and case reports have been published in the literature; therefore, overall survival (OS) outcome and the as-yet poorly defined management options are not discussed in detail. The authors performed a cumulative survival analysis of all reported cases of pediatric spinal cord GBM to identify the predictive factors related to final survival outcome. METHODS A comprehensive search for relevant articles was performed on PubMed's electronic database MEDLINE for the period from 1950 to 2015 using the search words "malignant spinal cord tumor" and "spinal glioblastoma multiforme." This study was limited to patients younger than 18 years of age. Survival rates for children with various tumor locations and treatments were collected from the published articles and analyzed. RESULTS After an extensive literature search, 29 articles met the study inclusion criteria. From the detailed information in these articles, the authors found 53 children eligible for the survival analysis. The majority (45%) of the children were more than 12 years old. Thirty-four percent of the cases were between 7 and 12 years of age, and 21% were younger than 7 years. In the Kaplan-Meier survival analysis, children younger than 7 years of age had better survival (13 months) than the children older than 7 years (7-12 years: 10 months, > 12 years: 9 months; p = 0.01, log-rank test). Fifty-five percent of the children were female and 45% were male. A cervical tumor location (32%) was the most common, followed by thoracic (28.3%). Cervicothoracic (18.9%) and conus (18.8%) tumor locations shared the same percentage of cases. Cervical tumors had a worse outcome than tumors in other locations (p = 0.003, log-rank test). The most common presenting symptom was limb weakness (53%), followed by sensory disturbances (25%). Median OS was 10 months. The addition of adjuvant therapy (radiotherapy [RT] and/or chemotherapy [CT]) after surgery significantly improved OS (p = 0.01, log-rank test). Children who underwent gross-total resection and RT had better outcomes than those who underwent subtotal resection and RT (p = 0.04, log-rank test). Cerebrospinal fluid spread, hydrocephalus, brain metastasis, and spinal metastasis were not correlated with OS in primary spinal GBM. CONCLUSIONS Adjuvant therapy after surgery had a beneficial effect on overall outcome of spinal GBM in the pediatric age group. Gross-total resection followed by RT produced a better outcome than subtotal resection with RT. Further large-scale prospective study is required to establish the genetic and molecular factors related to OS in primary GBM of the spinal cord in pediatric patients.

Relevance of Simpson grading system and recurrence-free survival after surgery for World Health Organization Grade I meningioma.

OBJECTIVE The clinical significance of the Simpson system for grading the extent of meningioma resection and its role as a predictor of the recurrence of World Health Organization (WHO) Grade I meningiomas have been questioned in the past, echoing changes in meningioma surgery over the years. The authors reviewed their experience in resecting WHO Grade I meningiomas and assessed the association between extent of resection, as evaluated using the Simpson classification, and recurrence-free survival (RFS) of patients after meningioma surgery. METHODS Clinical and radiological information for patients with WHO Grade I meningiomas who had undergone resective surgery over the past 20 years was retrospectively reviewed. Simpson and Shinshu grading scales were used to evaluate the extent of resection. Statistical analysis was conducted using Kaplan-Meier curves and Cox proportional-hazards regression. RESULTS Four hundred fifty-eight patients were eligible for analysis. Overall tumor recurrence rates for Simpson resection Grades I, II, III, and IV were 5%, 22%, 31%, and 35%, respectively. After Cox regression analysis, Simpson Grade I (extensive resection) was revealed as a significant predictor of RFS (p = 0.003). Patients undergoing Simpson Grade I and II resections showed significant improvement in RFS compared with patients undergoing Grade III and IV resections (p = 0.005). Extent of resection had a significant effect on recurrence rates for both skull base (p = 0.047) and convexity (p = 0.012) meningiomas. Female sex and a Karnofsky Performance Scale score > 70 were also identified as independent predictors of RFS after resection of WHO Grade I meningioma. CONCLUSIONS In this patient cohort, a significant association was noted between extent of resection and rates of tumor recurrence. In the authors' experience the Simpson grading system maintains its relevance and prognostic value and can serve an important role for patient education. Even though complete tumor resection is the goal, surgery should be tailored to each patient according to the risks and surgical morbidity.

Evaluation of Ventriculoperitoneal Shunt-Related Complications in Intracranial Meningioma with Hydrocephalus.

Objective Meningioma is a common intracranial tumor that predisposes patients to hydrocephalus which may require a permanent cerebrospinal fluid (CSF) diversion procedure such as ventriculoperitoneal (VP) shunts. We reviewed our long-term experience with VP shunts for the management of hydrocephalus in patients with meningioma. Methods and Materials A total of 48 Patients with meningioma who underwent VP shunt insertion for hydrocephalus from 1990 to 2013 was included in our case series. The study population was evaluated clinically and radiographically after VP shunt placement. Results Overall shunt failure was seen in 13 (27%) patients. Single and multiple shunt revisions were required in eight (16.7%) and five (10.4%) patients, respectively. The overall shunt revision within 6 months, 1 , and 5 years was 19, 23, and 27%, respectively. Male patient was significantly associated with the longer survival after shunt placement. Revisions free survival after 3, 5, 10, and 15 years of VP shunt placement were 70, 46, 30, and 20%, respectively. Finally, in regression analysis, age greater than 65 years (p = 0.02, 95% confidence interval (CI) = 0.1-0.13), tumor in posterior fossa (p < 0.0001, 95% CI = 0.1-0.23), tumor size (> 5 cm) (p = 0.3, 95% CI = 0.01-0.19), and Simpson resection grades II to IV (p = 0.04, 95% CI = 0.07-0.2) were identified as positive predictors of requirement of CSF flow diversion Conclusion The findings of the present study reveal that VP shunting is an important treatment option for the management of hydrocephalus in patients with meningioma. Further studies using less invasive techniques are warranted to compare the benefits of VP shunt for the management of hydrocephalus.

Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Single Surgeon's Experience over 16 Years.

BACKGROUND: Unruptured intracranial aneurysms (UIAs) have become an issue of greater significance as their detection rates have increased over the years. We present the overall experience of microsurgical clipping of unruptured aneurysms by a single surgeon over a period of more than 16 years. METHODS: The clinical and radiologic data were reviewed retrospectively. Clinical outcome at follow-up was assessed with Glasgow Outcome Scale, and angiograms were reviewed for the degree of occlusion. RESULTS: One hundred ninety-six patients with 221 UIAs were included in the analysis. The median age of patients was 54 years, with a female preponderance. Eighty-two percent of the patients had chronic headache on presentation. Middle cerebral artery aneurysms (32.2%) and posterior-inferior-cerebellar-artery aneurysms (46.1%) were most common in the anterior and posterior circulation, respectively. The perioperative complication rate was 17.3%. The overall surgical morbidity and mortality were 2.1% and 1.5%, respectively. With median follow-up of 11.3 months, 82% of patients were almost asymptomatic with a complete occlusion rate of 94%. The proportion of UIAs being coiled has significantly increased in the last decade, with a concomitant increase in the risk of poor clinical outcome after surgery. CONCLUSION: Surgical clipping is effective and can provide a good long-term outcome. The most commendable consequence that it provides is a better long-term occlusion rate. The experience of the individual surgeon is important for a superior and enduring overall outcome. An increase in the rate of coiling in recent years has affected the outcome rate after surgery that calls for further evaluation.