Clinical characteristics and outcomes after trigeminal schwannoma resection: a multi-institutional experience.

Given their rarity, the clinical course of patients undergoing trigeminal schwannoma (TS) resection remains understudied. The objective of this study is to describe clinical characteristics and outcomes in patients undergoing surgical resection for TS in a multi-institutional cohort. This is a retrospective study of patients undergoing TS resection at two institutions between 2004 and 2022. Patient, radiographic, and clinical characteristics were reviewed and analyzed with standard statistical methods. Thirty patients were included. The median patient age was 43 (IQR: 35-52) years, and 14 (47%) patients were female. Median clinical and radiographic follow-ups were 43 (IQR: 20-81) and 47 (IQR: 27-97) months respectively. The most common presenting symptoms were trigeminal hypesthesia (57%) and headaches (30%), diplopia (30%), and ataxia/cerebellar signs (30%). The median maximum tumor diameter was 3.3 (IQR: 2.5-5.4) cm. Most tumors were Samii type C (50%) and mixed cystic-solid (63%). Surgical approaches included endoscopic endonasal (33%), supratentorial (30%), combined/staged (20%), infratentorial (10%), and anterior petrosal (7%) approaches. Gross-total resection was achieved in 16 (53%) patients. Radiographic tumor recurrence was noted in four patients at a median of 79 (range 5-152) months. Twenty-six (87%) patients reported improvements in at least one symptom by last follow-up. The most common perioperative complication was new cranial nerve deficit, with 17% of patients having a transient deficit and 10% having a permanent cranial nerve deficit. Surgical resection of TS showed good progression-free survival and symptom improvement, but was associated with cranial nerve deficits.

Outcomes following surgical resection of trigeminal schwannomas: a systematic review and meta-analysis.

Although typically benign, trigeminal schwannomas (TS) may require surgical resection when large or symptomatic and can cause significant morbidity. This study aims to summarize the literature and synthesize outcomes following surgical resection of TS. A systematic review was performed according to PRISMA guidelines. Data extracted included patient and tumor characteristics, surgical approaches, and postoperative outcomes. Odds ratios (OR) with corresponding 95% confidence intervals (CI) were used for outcome analysis. The initial search yielded 1838 results, of which 26 studies with 974 patients undergoing surgical resection of TS were included. The mean age was 42.9 years and 58.0% were female. The mean tumor diameter was 4.7 cm, with Samii type A, B, C, and D tumors corresponding to 33.4%, 15.8%, 37.2%, and 13.6%, respectively. Over a mean symptom duration of 29 months, patients presented with trigeminal hypesthesia (58.7%), headache (32.8%), trigeminal motor weakness (22.8%), facial pain (21.3%), ataxia (19.4%), diplopia (18.7%), and visual impairment (12.0%). Surgical approaches included supratentorial (61.4%), infratentorial (15.0%), endoscopic (8.6%), combined/staged (5.3%), and anterior (5.7%) or posterior (4.0%) petrosectomy. Postoperative improvement of facial pain (83.9%) was significantly greater than trigeminal motor weakness (33.0%) or hypesthesia (29.4%). The extent of resection (EOR) was reported as gross total (GTR), near total, and subtotal in 77.7%, 7.7%, and 14.6% of cases, respectively. Over a mean follow-up time of 62.6 months, recurrence/progression was noted in 7.4% of patients at a mean time to recurrence of 44.9 months. Patients with GTR had statistically significantly lower odds of recurrence/progression (OR: 0.07; 95% CI: 0.04-0.15) compared to patients with non-GTR. This systematic review and meta-analysis report patient outcomes following surgical resection of TS. EOR was found to be an important predictor of the risk of recurrence. Facial pain was more likely to improve postoperatively than facial hypesthesia. This work reports baseline rates of post-operative complications across studies, establishing benchmarks for neurosurgeons innovating and working to improve surgical outcomes for TS patients.

Chiari malformation type 1 presenting as isolated unilateral foot drop with rapid recovery following posterior fossa decompression.

BACKGROUND: Chiari malformation (CM) type 1 is characterized by descent of the cerebellar tonsils resulting from crowding of the posterior fossa. In 30% of cases, it is associated with syringomyelia. When symptomatic, it may result in a classic constellation of symptoms. CASE PRESENTATION: Here we describe a case of a 16-year-old male who presented with isolated, unilateral foot drop due to CM type 1 and holosyrinx. This unique presentation is extremely rare, and we additionally present a review of all other reported cases in the literature. After undergoing posterior fossa decompression with C1 laminectomy and duraplasty, our patient made a complete neurological recovery within 2 weeks postoperatively and his MRI entire spine at 3 months postoperatively demonstrated a nearly complete resolution of the holosyrinx with significant decompression of the foramen magnum. CONCLUSION: This rare presentation highlights the importance of maintaining a broad differential, particularly in pediatric patients, and expediting the workup in order to offer a surgical decompression within 1-2 months of foot weakness to maximize the probability of a full neurological recovery.

Presentation, management and outcome of surgically managed pediatric thoracic outlet syndrome.

PURPOSE: Thoracic outlet syndrome (TOS) is a rare disorder involving compression of the brachial plexus, subclavian artery, and subclavian vein. There is a paucity of data for this pathology's surgical treatment within pediatrics. The objective of this study is to explore the presentation, management, and outcome of pediatric TOS. METHODS: A retrospective chart review was conducted for 44 patients at a single institution undergoing surgery for TOS. Data was collected on demographics, pre- and postoperative factors, and outcomes. RESULTS: Forty-four patients underwent 50 surgeries (8 bilaterally). The average age was 15.5 years with 72% female. The most common symptoms were numbness (72%) and pain (66%), with a normal exam in 58%. The average symptom duration prior to surgery was 35.2 months. A supraclavicular approach was performed in all patients, with anterior scalene section (90%), rib resection (72%), neurolysis (92%), and intraoperative EMG (84%) commonly used. Two patients had a lymphatic leak. All patients reported subjective improvement of preoperative symptoms of numbness (26%), pain (22%), and weakness (6%). Differences between vTOS (n = 9) and nTOS (n = 35) included higher preop swelling (p < 0.012), decreased symptom duration (p < 0.022), higher venogram usage (p < 0.0030), and higher preoperative thrombolytics/angioplasty (p < 0.001) in vTOS compared to nTOS. A comparison of soft tissue and soft tissue with bone decompression did not reveal any outcome differences. CONCLUSION: Pediatric TOS benefits from a multidisciplinary approach, showing good outcomes in postoperative symptom resolution. In our cohort, a supraclavicular approach provided an effective window for decompression with a low complication rate.

The role of neurosurgery in the management of tuberous sclerosis complex-associated epilepsy: a systematic review.

OBJECTIVE: Tuberous sclerosis complex (TSC) is an autosomal dominant, multisystem neurocutaneous disorder associated with cortical tubers, brain lesions seen in nearly all patients with TSC, which are frequently epileptogenic. Seizures are often the earliest clinical manifestation of TSC, leading to epilepsy in over 70% of patients. Medical management with antiepileptic drugs constitutes early therapy, but over 50% develop medically refractory epilepsy, necessitating surgical evaluation and treatment. The objective of this study was to summarize the literature and report seizure outcomes following surgical treatment for TSC-associated epilepsy. METHODS: A systematic literature review was performed in accordance with the PRISMA guidelines. The PubMed and Embase databases were searched for journal articles reporting seizure outcomes following epilepsy surgery in TSC patients. Included studies were placed into one of two groups based on the surgical technique used. Excellent and worthwhile seizure reductions were defined for each group as outcomes and extracted from each study. RESULTS: A total of 46 studies were included. Forty of these studies reported seizure outcomes following any combination of resection, disconnection, and ablation on a collective 1157 patients. Excellent and worthwhile seizure reductions were achieved in 59% (683/1157) and 85% (450/528) of patients, respectively. Six of these studies reported seizure outcomes following treatment with neuromodulation. Excellent and worthwhile seizure reductions were achieved in 34% (24/70) and 76% (53/70) of patients, respectively. CONCLUSIONS: Surgery effectively controls seizures in select patients with TSC-associated epilepsy, but outcomes vary. Further understanding of TSC-associated epilepsy, improving localization strategies, and emerging surgical techniques represent promising avenues for improving surgical outcomes.

Outcomes following stereotactic radiosurgery for foramen magnum meningiomas: a single-center experience and systematic review of the literature.

OBJECTIVE: Foramen magnum meningiomas (FMMs) pose a unique challenge given their intimate anatomical relationship with the craniovertebral junction. While resection has been studied extensively, much less has been reported about the use of stereotactic radiosurgery (SRS) for FMMs. This study includes what is to the authors' knowledge the first systematic review in the literature that summarizes patient and treatment characteristics and synthesizes outcomes following SRS for FMMs. METHODS: A retrospective chart review was conducted at a single major academic institution, and a systematic review was performed according to PRISMA guidelines. The initial search on the PubMed and Scopus databases yielded 530 results. Key data extracted from both databases included Karnofsky Performance Status (KPS) score and neurological deficits at presentation, tumor location, treatment indication, target volume, single versus multiple fractions, marginal and maximum doses, isodose line, clinical and radiographic follow-up times, and primary (clinical stability and local control at last follow-up) and secondary (mortality, adverse radiation events, time to regression, progression-free survival) outcomes. RESULTS: The study patients included 9 patients from the authors' institution and 165 patients across 4 studies who received SRS for FMMs. The weighted median age at treatment was 60.2 years, and 73.9% of patients were female. Common presenting symptoms included headache (33.9%), dizziness/ataxia (29.7%), cranial nerve deficit(s) (27.9%), numbness (22.4%), weakness (15.2%), and hydrocephalus (4.2%). Lateral/ventrolateral (64.2%) was the most common tumor location. SRS was utilized as the primary therapy in 63.6% of patients and as salvage (21.8%) or adjuvant (14.5%) therapy for the rest of the patients. Most patients (91.5%) were treated with a single fraction. A tumor with a weighted median target volume of 2.9 cm3 was treated with a weighted median marginal dose, maximum dose, and isodose line of 12.9 Gy, 22.8 Gy, and 58%, respectively. Clinical stability and local control at last follow-up were achieved in 98.8% and 97.0% of patients, respectively. Only one possible adverse radiation event occurred, and no mortality directly related to the tumor or SRS was reported. CONCLUSIONS: In this retrospective analysis and systematic review, the authors demonstrate SRS to be an effective and safe treatment option for carefully selected patients with FMMs.

Overview of medical malpractice in neurosurgery.

Annually, 20% of all practicing neurosurgeons in the United States are faced with medical malpractice litigation. The average indemnity paid in a closed neurosurgical civil claim is $439,146, the highest of all medical specialties. The majority of claims result from dissatisfaction following spinal surgery, although claims after cranial surgery tend to be costlier. On a societal scale, the increasing prevalence of medical malpractice claims is a catalyst for the practice of defensive medicine, resulting in record-level healthcare costs. Outside of the obvious financial strains, malpractice claims have also been linked to professional disenchantment and career changes for afflicted physicians. Unfortunately, neurosurgical residents receive minimal practical education regarding these matters and are often unprepared and vulnerable to these setbacks in the earlier stages of their careers. In this article, the authors aim to provide neurosurgical residents and junior attendings with an introductory guide to the fundamentals of medical malpractice lawsuits and the implications for neurosurgeons as an adjunct to more formal residency education.

Pipeline embolization device for recurrence of previously treated aneurysms.

OBJECTIVE The utilization of the Pipeline embolization device (PED) has increased significantly since its inception and original approval for use in large, broad-necked aneurysms of the internal carotid artery. While microsurgical clipping and advances in endovascular techniques have improved overall efficacy in achieving complete occlusion, recurrences still occur, and the best modality for retreatment remains controversial. Despite its efficacy in this setting, the role of PED utilization in the setting of recurrent aneurysms has not yet been well defined. This study was designed to assess the safety and efficacy of PED in the recurrence of previously treated aneurysms. METHODS The authors reviewed a total of 13 cases in which patients underwent secondary placement of a PED for aneurysm recurrence following prior treatment with another modality. The PEDs were used to treat aneurysm recurrence or residual following endovascular coiling in 7 cases, flow diversion in 2, and microsurgical clipping in 4. The mean time between initial treatment and retreatment with a PED was 28.1 months, 12 months, and 88.7 months, respectively. Clinical outcomes, including complications and modified Rankin Scale (mRS) scores, and angiographic evidence of complete occlusion were tabulated for each treatment group. RESULTS All PEDs were successfully placed without periprocedural complications. The rate of complete occlusion was 80% at 6 months after PED placement and 100% at 12 months in these patients who underwent PED placement following failed endovascular coiling; there were no adverse clinical sequelae at a mean follow-up of 26.1 months. In the 2 cases in which PEDs were placed for treatment of residual aneurysms following prior flow diversion, 1 patient demonstrated asymptomatic vessel occlusion at 6 months, and the other exhibited complete aneurysm occlusion at 12 months. In patients with aneurysm recurrence following prior microsurgical clipping, the rate of complete occlusion was 100% at 6 and 12 months, with no adverse sequelae noted at a mean clinical follow-up of 27.7 months. CONCLUSIONS The treatment of recurrent aneurysms with the PED following previous endovascular coiling, flow diversion, or microsurgical clipping is associated with a high rate of complete occlusion and minimal morbidity.

The Evolving Classification of Meningiomas: Integration of Molecular Discoveries to Inform Patient Care.

Meningioma classification and treatment have evolved over the past eight decades. Since Bailey, Cushing, and Eisenhart's description of meningiomas in the 1920s and 1930s, there have been continual advances in clinical stratification by histopathology, radiography and, most recently, molecular profiling, to improve prognostication and predict response to therapy. Precise and accurate classification is essential to optimizing management for patients with meningioma, which involves surveillance imaging, surgery, primary or adjuvant radiotherapy, and consideration for clinical trials. Currently, the World Health Organization (WHO) grade, extent of resection (EOR), and patient characteristics are used to guide management. While these have demonstrated reliability, a substantial number of seemingly benign lesions recur, suggesting opportunities for improvement of risk stratification. Furthermore, the role of adjuvant radiotherapy for grade 1 and 2 meningioma remains controversial. Over the last decade, numerous studies investigating the molecular drivers of clinical aggressiveness have been reported, with the identification of molecular markers that carry clinical implications as well as biomarkers of radiotherapy response. Here, we review the historical context of current practices, highlight recent molecular discoveries, and discuss the challenges of translating these findings into clinical practice.

Predictors of salvage therapy for parasagittal meningiomas treated with primary surgery, radiosurgery, or surgery plus adjuvant radiotherapy.

OBJECTIVE: Parasagittal meningiomas (PM) are treated with primary microsurgery, radiosurgery (SRS), or surgery with adjuvant radiation. We investigated predictors of tumor progression requiring salvage surgery or radiation treatment. We sought to determine whether primary treatment modality, or radiologic, histologic, and clinical variables were associated with tumor progression requiring salvage treatment. METHODS: Retrospective study of 109 consecutive patients with PMs treated with primary surgery, radiation (RT), or surgery plus adjuvant RT (2000-2017) and minimum 5 years follow-up. Patient, radiologic, histologic, and treatment data were analyzed using standard statistical methods. RESULTS: Median follow up was 8.5 years. Primary treatment for PM was surgery in 76 patients, radiation in 16 patients, and surgery plus adjuvant radiation in 17 patients. Forty percent of parasagittal meningiomas in our cohort required some form of salvage treatment. On univariate analysis, brain invasion (OR: 6.93, p < 0.01), WHO grade 2/3 (OR: 4.54, p < 0.01), peritumoral edema (OR: 2.81, p = 0.01), sagittal sinus invasion (OR: 6.36, p < 0.01), sagittal sinus occlusion (OR: 4.86, p < 0.01), and non-spherical shape (OR: 3.89, p < 0.01) were significantly associated with receiving salvage treatment. On multivariate analysis, superior sagittal sinus invasion (OR: 8.22, p = 0.01) and WHO grade 2&3 (OR: 7.58, p < 0.01) were independently associated with receiving salvage treatment. There was no difference in time to salvage therapy (p = 0.11) or time to progression (p = 0.43) between patients receiving primary surgery alone, RT alone, or surgery plus adjuvant RT. Patients who had initial surgery were more likely to have peritumoral edema on preoperative imaging (p = 0.01). Median tumor volume was 19.0 cm3 in patients receiving primary surgery, 5.3 cm3 for RT, and 24.4 cm3 for surgery plus adjuvant RT (p < 0.01). CONCLUSION: Superior sagittal sinus invasion and WHO grade 2/3 are independently associated with PM progression requiring salvage therapy regardless of extent of resection or primary treatment modality. Parasagittal meningiomas have a high rate of recurrence with 80.0% of patients with WHO grade 2/3 tumors with sinus invasion requiring salvage treatment whereas only 13.6% of the WHO grade 1 tumors without sinus invasion required salvage treatment. This information is useful when counseling patients about disease management and setting expectations.

Outcomes following anterior odontoid screw versus posterior arthrodesis for odontoid fractures: a systematic review and meta-analysis.

OBJECTIVE: Odontoid fractures can be managed surgically when indicated. The most common approaches are anterior dens screw (ADS) fixation and posterior C1-C2 arthrodesis (PA). Each approach has theoretical advantages, but the optimal surgical approach remains controversial. The goal in this study was to systematically review the literature and synthesize outcomes including fusion rates, technical failures, reoperation, and 30-day mortality associated with ADS versus PA for odontoid fractures. METHODS: A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by searching the PubMed, EMBASE, and Cochrane databases. A random-effects meta-analysis was performed and the I2 statistic was used to assess heterogeneity. RESULTS: In total, 22 studies comprising 963 patients (ADS 527, PA 436) were included. The average age of the patients ranged from 28 to 81.2 years across the included studies. The majority of the odontoid fractures were type II based on the Anderson-D'Alonzo classification. The ADS group was associated with statistically significantly lower odds to achieve bony fusion at last follow-up compared to the PA group (ADS 84.1%; PA 92.3%; OR 0.46; 95% CI 0.23-0.91; I2 42.6%). The ADS group was associated with statistically significantly higher odds of reoperation compared to the PA group (ADS 12.4%; PA 5.2%; OR 2.56; 95% CI 1.50-4.35; I2 0%). The rates of technical failure (ADS 2.3%; PA 1.1%; OR 1.11; 95% CI 0.52-2.37; I2 0%) and all-cause mortality (ADS 6%; PA 4.8%; OR 1.35; 95% CI 0.67-2.74; I2 0%) were similar between the two groups. In the subgroup analysis of patients > 60 years old, the ADS was associated with statistically significantly lower odds of fusion compared to the PA group (ADS 72.4%; PA 89.9%; OR 0.24; 95% CI 0.06-0.91; I2 58.7%). CONCLUSIONS: ADS fixation is associated with statistically significantly lower odds of fusion at last follow-up and higher odds of reoperation compared to PA. No differences were identified in the rates of technical failure and all-cause mortality. Patients receiving ADS fixation at > 60 years old had significantly higher and lower odds of reoperation and fusion, respectively, compared to the PA group. PA is preferred to ADS fixation for odontoid fractures, with a stronger effect size for patients > 60 years old.

Gamma Knife Radiosurgery for Spetzler-Martin Grade III Brain Arteriovenous Malformations.

BACKGROUND: Spetzler-Martin (SM) grade III arteriovenous malformations (AVMs) show angioarchitecture heterogeneity and lack a clearly defined treatment strategy. This study aims to evaluate outcomes after treatment of SM grade III AVMs with Gamma Knife radiosurgery (GKRS). METHODS: A single-institution retrospective analysis was conducted of 307 patients with SM grade III AVMs undergoing GKRS between October 2006 and December 2020 with follow-up times of at least 24 months. SM grade III AVMs were classified into 4 subtypes: IIIA (S1E1V1), IIIB (S2E0V1), subtype IIIC (S2E1V0), and IIID (S3E0V0). RESULTS: Over a median follow-up time of 50.3 months, complete AVM obliteration was achieved in 211 patients (68.7%). Complete obliteration rates in subtypes IIIA, IIIB, IIIC, and IIID were 80.8%, 55.4%, 53.4%, and 25.0%, respectively. Annual post-GKRS hemorrhage risk was 0.8%. Significant radiosurgery-induced imaging changes occurred in 7 patients (2.3%). Three variables were identified as predictors of obliteration in final forward stepwise regression models, including volume of AVM (B = -0.011; P < 0.001), age (B = -0.004; P = 0.024), and previous AVM hemorrhage (B = 0.187; P = 0.077). CONCLUSIONS: GKRS is a safe and effective treatment for SM grade III AVMs, particularly subtype IIIA (S1E1V1). AVM volume is the key predictor of post-GKRS obliteration.

Repeat Surgery for Vestibular Schwannomas: An Institutional Case Series.

Introduction Vestibular schwannomas (VSs) are treated with microsurgery and/or radiosurgery. Repeat resection is rare, and few studies have reported postoperative outcomes. The objective of this study was to describe clinical characteristics and outcomes in patients undergoing repeat surgery for VS. Methods All adult (≥ 18 years) patients undergoing VS resection between 2003 and 2022 at our institution were retrospectively reviewed to identify patients who underwent repeat surgery of an ipsilateral VS following prior gross-total (GTR) or subtotal resection. Patient, radiographic, and clinical characteristics were reviewed. Primary outcomes were postoperative tumor volume, extent of resection, postoperative cranial nerve deficits, and time to further tumor progression. Results Of 102 patients undergoing VS resection, 6 (5.9%) had undergone repeat surgery. Median (range) follow-up was 20 (5-117) months. Three patients were female. Median age was 56 (36-60) years. Median pre- and postoperative tumor volumes were 8.2 (1.8-28.2) cm 3 and 0.4 (0-3.8) cm 3 . GTR was achieved in two patients. Four patients had higher House-Brackmann scores at last follow-up, but none had tumor progression. Conclusion In this small cohort of patients, repeat resection of recurrent or progressive VS can effectively reduce tumor volume with acceptable perioperative outcomes.

Post-Surgical Prognosis of Patients with Pineoblastoma: A Systematic Review and Individual Patient Data Analysis with Trends over Time.

Most of the literature on pineoblastoma consists of case reports and single-institution series. The goal of this systematic review and individual patient data (IPD) analysis was to summarize the existing literature, identify factors associated with overall survival (OS), and provide a contemporary update on prognosis for patients with pineoblastoma. Forty-four studies were identified with 298 patients having IPD. Kaplan-Meier analyses were used to report survival outcomes based on age, tumor metastases, extent of resection (EOR), adjuvant therapy, and publication year. Cox regression was performed to identify independent predictors of time to mortality. Multivariable recursive partitioning analysis was used to identify the most important subgroups associated with mortality. Patients were classified based on publication year before and after the last systematic review on this topic (pre-2012 and 2012 onwards) and compared using univariate and multivariable analyses. This study demonstrates that EOR less-than-gross total resection, metastatic presentation, adjuvant chemotherapy without radiation, and tumor presentation in children less than three years old are associated with poorer prognosis. Since 2012, the 5-year actuarial OS has improved from 32.8% to 56.1%, which remained significant even after accounting for EOR, age, and adjuvant therapy. Pineoblastoma remains a severe rare disease, but survival outcomes are improving.

Analysis of socioeconomic and demographic factors on post-treatment outcomes for metastatic spinal tumors.

OBJECTIVE: Sociodemographic factors may play a role in incidence and treatment of metastatic spinal tumors, as there is a delay in diagnosis and increased incidence of relevant primaries. There has yet to be a detailed analysis of the impact of sociodemographic factors on surgical outcomes for spinal metastases. We sought to examine the influence of socioeconomic factors on outcomes for patients with metastatic spinal tumors. METHODS: Two hundred and sixty-three patients who underwent surgery for metastatic spinal tumors were identified. Sociodemographic characteristics were then collected and assigned to patients based on their ZIP code. The Chi-square test and the Mann-Whitney-U test were used for binary and continuous variables, respectively. Multivariate regression models were also used to control for age, smoking status, body mass index, and Charlson Comorbidity Index. RESULTS: Males had significantly lower rates of post-treatment complication compared to females (22.7 % vs 39.3 %, p = 0.0052), and those in high educational attainment ZIP codes had significantly shorter length of stay (LOS) compared to low educational attainment ZIP codes (9.3 days vs 12.2 days, p = 0.0058). Multivariate regression revealed that living in a high percentage white ZIP code and being male significantly decreased risk of post-treatment complication by 19 % (p = 0.042) and 14 % (p = 0.032), respectively. Living in a high educational attainment ZIP code decreased LOS by 3 days (p = 0.019). CONCLUSIONS: Males had significantly lower rates of post-treatment complication. Patients in high percentage white areas also had decreased rate of post-treatment complications. Patients living in areas with high educational attainment had shorter length of stay.

Validating the VS-5 Score for Predicting Outcomes After Vestibular Schwannoma Resection in an Institutional Cohort.

BACKGROUND: The VS-5 index was recently proposed to predict complications, nonroutine discharge, length of stay (LOS), and cost after vestibular schwannoma (VS) resection. The VS-5 ranges from 0-17.86, and a score ≥2 was proposed as being predictive of postoperative adverse events. We sought to determine whether the VS-5 is predictive of nonroutine discharge and length of stay in an institutional cohort. METHODS: This is a retrospective study of 100 patients undergoing VS resection. For each patient, a VS-5 score was calculated. Bivariate analyses were conducted to determine differences in postoperative outcomes between high- and low-risk subgroups. Area under the receiver operating characteristic curve sensitivity/specificity analysis using Youden's Index was conducted to evaluate the optimal cutoff. RESULTS: Fifty-one (51%) patients were classified as high risk (VS-5 ≥ 2). Patients with VS-5 ≥ 2 had higher frequency of nonroutine discharge (22% vs. 4%, P = 0.0150) and no significant difference in postoperative LOS. The area under the receiver operating characteristic curve for predicting nonroutine discharge was 0.78 ± 0.15 (P < 0.0001). The optimal cutoff for nonroutine discharge was ≥6, higher than the published cutoff of ≥ 2. The new cutoff was predictive of nonroutine discharge (47% vs. 6%, P = 0 < 0.0001) and LOS (6 [3-11] days vs. 3 [1-28] days, P = 0.0001). CONCLUSIONS: The VS-5 frailty index predicted nonroutine discharge but not LOS. Youden's index indicates that a cutoff of 6, not 2, is optimal for predicting nonroutine discharge and LOS.

Impact of Postoperative Stereotactic Body Radiation Therapy on Survival of Patients with Spinal Metastases in the Context of Additional Systemic Adjuvant Therapy.

BACKGROUND: Stereotactic body radiotherapy (SBRT) has been established as a safe and effective treatment modality for control of long-term pain and tumor growth. However, few studies have investigated the efficacy of postoperative SBRT versus conventional external beam radiation therapy (EBRT) in extending survival within the context of systemic therapy. METHODS: A retrospective chart review of patients who underwent surgery for spinal metastasis at our institution was conducted. Demographic, treatment, and outcome data were collected. SBRT was compared with EBRT and non-SBRT, and analyses were stratified by whether patients received systemic therapy. Survival analysis was conducted using propensity score matching. RESULTS: Bivariate analysis in the nonsystemic therapy group revealed longer survival with SBRT compared with EBRT and non-SBRT. Further analysis also showed that primary cancer type and preoperative mRS significantly affected survival. Within patients who received systemic therapy, overall median survival for patients receiving SBRT was 22.7 months (95% confidence interval [CI] 12.1-52.3) versus 16.1 months (95% CI 12.7-44.0; P = 0.28) for patients who received EBRT and 16.1 months (95% CI: 12.2-21.9; P = 0.07) for patients without SBRT. Within patients who did not receive systemic therapy, overall median survival for patients with SBRT was 62.1 months (95% CI 18.1-unknown) versus 5.3 months (95% CI 2.8-unknown; P = 0.08) for patients with EBRT and 6.9 months (95% CI 5.0-45.6; P = 0.02) for patients without SBRT. CONCLUSIONS: In patients who do not receive systemic therapy, treatment with postoperative SBRT may increase survival time compared with patients not receiving SBRT.

Outpatient telemedicine in neurosurgery: 15,677 consecutive encounters in a comparative analysis of its effectiveness and impact on the surgical conversion rate.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has necessitated the use of telehealth visits (THVs). The effects on neurosurgical practice have not been well characterized, especially concerning new-patient THVs. Therefore, the authors of this study reviewed their institution's experience with outpatient clinic visits and THVs from before the COVID-19 pandemic to the present to focus on clinical metrics, rates of surgery, and the effects of implementing THVs in order to better understand their implications for clinical practice as more data emerge over time. METHODS: The authors reviewed 15,677 consecutive new outpatient in-person visits (IPVs), THVs, and neurosurgical procedures/cases proceeding from their institution between 2018 and 2022 for trends and associations related to THVs. RESULTS: Among spine patients, there was no difference in the proportion of encounters that led to surgery (surgical conversion rate) between THVs and IPVs (p = 0.49). Among cranial patients, THVs were negatively associated with conversion (OR 0.73, p = 0.03). On average, patients using THVs lived further from the hospital (p < 0.001); however, the patient catchment area appeared unchanged. The median distance to the hospital among THV patients was counterbalanced by a decreased distance for spine patients pursing IPVs (p < 0.001), with no significant change to case volume. There was no change in distance to the hospital among cranial patients. For both cranial and spine patients, surgical conversion was more likely among those who lived a great distance from the hospital if their initial encounter was an IPV (p = 0.007 and < 0.001, respectively). However, there was no relationship between distance from the hospital and surgical conversion among THV patients (p = 0.565). The availability of THVs did not significantly affect follow-up time (p = 0.837). For new patients at IPVs, there was no difference in time to the operating room between cranial and spine cases; for new patients at THVs, however, time to the operating room was significantly faster for cranial cases than for spine cases (p = 0.0018). CONCLUSIONS: Compared to IPVs, THVs lead to decreased surgical conversion for cranial patients but not spine patients. THVs do not appear to increase the catchment area. For patients who live far from the hospital, an IPV is associated with surgical conversion. Surgical conversion is faster following cranial THVs than after spine THVs. THVs did not increase the duration of follow-up.

A Systematic Review of Outpatient Telemedicine Use in Neurosurgery Since the Start of Coronavirus Disease 2019.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has sparked interest in telemedicine, resulting in an increase in neurosurgical publications focused on it. We summarize this new literature to evaluate telemedicine applications to neurosurgery. METHODS: A systematic literature review was performed in accordance with the PRISMA guidelines by searching PubMed, Embase, and Scopus for journal articles published after January 1, 2020. All journal articles that included data after the start of COVID-19 and evaluated any aspect of telemedicine relevant to outpatient neurosurgical visits were included. The premise and key findings of each included study were extracted, as well as patient and provider satisfaction with and preference for telemedicine. RESULTS: Thirty-seven articles met the inclusion criteria. Four studies proposed and evaluated a remote neurologic examination. Two studies reported similar postvisit outcomes between remote and in-person visits. Twenty-four studies reported a combination of patient and provider opinions toward telemedicine. Of 9834 patients and 116 providers, 82.4% and 65.2% were satisfied overall with telemedicine, respectively. Of 3526 patients and 168 providers, 57.0% and 66.5% preferred telemedicine to in-person visits, respectively. CONCLUSIONS: Overall, most patients and providers have a high opinion of telemedicine for outpatient visits, and increasing evidence suggests that remote visits yield favorable clinical outcomes. The high rates of patient and provider satisfaction and preference may be considered for further adoption of remote neurosurgical visits beyond the COVID-19 era.

Gamma Knife Radiosurgery for Brain Arteriovenous Malformations: A 15-Year Single-Center Experience in Southern Vietnam.

BACKGROUND: In the present study, we aimed to identify the obliteration outcomes, complications, and predictors in gamma knife radiosurgery (GKRS) treatment of brain arteriovenous malformations (AVMs) at a tertiary center in a developing country in a 15-year experience. METHODS: We retrospectively reviewed the clinical data and GKRS procedures of patients who had undergone GKRS from 2006 to 2011 (cohort 1) and from 2011 to 2020 (cohort 2) at Cho Ray Hospital, Vietnam. The exclusion criteria included patients with <24 months of follow-up without obliteration or AVM-related hemorrhage during the study period. RESULTS: A total of 870 patients were included in the final analysis. The patients in cohort 1 had had significantly smaller AVMs (8.4 ± 11.6 cm3 vs. 11.2 ± 12.8 cm3; P < 0.001), and the AVMs were less frequently located in eloquent locations (46.6% vs. 65.5%; P < 0.001) than in cohort 2. The mean follow-up time was 49.6 ± 22.6 months (range, 5.9-102.6). The overall AVM obliteration rate was 66.6%. Cohort 1 had a significantly higher rate of complete obliteration compared with cohort 2 (81.0% vs. 55.1%; P < 0.001). The post-GKRS annual hemorrhage risk was 1.0%. Significant radiosurgery-induced brain edema and radiosurgery-induced cyst formation was reported in 24 (2.6%) and 4 (0.5%) patients in cohorts 1 and 2, respectively. Using multivariate analysis, we identified prior AVM hemorrhage (hazard ratio [HR], 1.430; 95% confidence interval [CI], 1.182-1.729), a higher margin dose (HR, 1.136; 95% CI, 1.086-1.188), a noneloquent location (HR, 0.765; 95% CI, 0.647-0.905), and smaller AVM volume (HR, 0.982; 95% CI, 0.968-0.997) as predictive factors for obliteration. CONCLUSIONS: GKRS is a safe and effective treatment of brain AVMs. The lack of prior AVM hemorrhage, an eloquent location, and higher AVM were unfavorable predictors for post-GKRS obliteration.