MOG Antibody-Associated Disease in the Setting of Metastatic Melanoma Complicated by Immune Checkpoint Inhibitor Use.

OBJECTIVES: Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an autoimmune demyelinating disease rarely associated with malignancy. We report the clinical, MRI, immunopathology, and treatment response in a person with MOGAD and melanoma. METHODS: This is a case report of a person with a multidisciplinary evaluation at a tertiary referral center. RESULTS: A 52-year-old man presented with progressive encephalomyelitis that led to identification of metastatic melanoma. Investigations revealed positive MOG-IgG at high titers in serum (1:1,000; normal, <1:20) and CSF (1:4,096; normal, <1:2). MRI demonstrated multifocal T2 lesions with enhancement in the brain and spine. Brain biopsy showed demyelination and inflammation. MOG immunostaining was not present in the tumor tissue. He initially improved with methylprednisolone, plasmapheresis, prolonged oral steroid taper, and cancer-directed treatment with BRAF and MEK 1/2 inhibitors, but then developed bilateral optic neuritis. IV immunoglobulin (IVIG) was initiated. Five months later, he developed metastases and immune checkpoint inhibitor (ICI) treatment was started, which precipitated optic neuritis and myelitis despite IVIG and prednisone. Tocilizumab, an interleukin-6 receptor blocker, was started with excellent and sustained clinical and radiologic response. DISCUSSION: This case revealed a presentation of MOGAD concurrent with melanoma without tumor MOG immunostaining. We highlight tocilizumab as a dual-purpose treatment of MOGAD and the neurologic immune-related adverse effect of ICI.

Objective Responses in Metastatic Pleomorphic Rhabdomyosarcoma Treated with Combination of Doxorubicin and Pembrolizumab: A Case Series.

Introduction: Pleomorphic rhabdomyosarcoma is a rare subtype of rhabdomyosarcoma, a soft tissue sarcoma with skeletal muscle differentiation. Although rhabdomyosarcoma is typically seen in the pediatric population, the pleomorphic variant most frequently presents in adulthood and is characteristically aggressive with no currently established treatment regimen in the setting of metastatic disease. There has been growing interest in the application of immune checkpoint inhibitors alongside conventional chemotherapeutic agents in the treatment of pleomorphic rhabdomyosarcoma. Case Presentation: In the present case series, we report 2 patients with metastatic pleomorphic rhabdomyosarcoma treated with combination doxorubicin and pembrolizumab who had confirmed objective responses. Of note, these 2 patients had variable PD-L1 status - negative and low positive. Duration of treatment response was notable at 14 months and 9 months, respectively, with the first patient remaining on maintenance pembrolizumab therapy and the second patient subsequently achieving complete response with third-line trabectedin. Both patients are currently undergoing routine interval imaging with no evidence of disease at this time. Conclusion: This report highlights and discusses the potential role of PD-1 blockade in the treatment of pleomorphic rhabdomyosarcoma and also discusses burgeoning immunological data that may explain the clinical responses seen in these 2 cases.

Risk factors for delirium in elderly patients after lumbar spinal fusion.

OBJECTIVE: To identify perioperative risk factors for postoperative delirium (POD) in patients aged 65 or older undergoing lumbar spinal fusion procedures. PATIENTS AND METHODS: A retrospective cohort analysis was performed on patients undergoing lumbar spinal fusion over an approximately three-year period at a single institution. Demographic and perioperative data were obtained from electronic medical records. The primary outcome was the presence of postoperative delirium assayed by the Delirium Observation Screening Scale (DOSS) and Confusion Assessment Method for the ICU (CAM-ICU). Univariate and multivariate analyses were performed on the data. RESULTS: Of the 702 patients included in the study, 173 (24.6%) developed POD. Our analysis revealed that older age (p < 0.001), lower preoperative hemoglobin (p < 0.001), and higher ASA status (p < 0.001), were significant preoperative risk factors for developing POD. The only significant intraoperative risk factor was a higher number of spinal levels that were instrumented (p < 0.001). Higher pain scores on postoperative day 1 (p < 0.001), and lower postoperative hemoglobin (p < 0.001) were associated with increased POD; as were ICU admission (p < 0.001) and increased length of ICU stay (p < 0.001). Patients who developed POD had a longer hospital stay (p < 0.001) with lower rates of discharge to home as opposed to an inpatient facility (p < 0.001). CONCLUSION: Risk factors for POD in older adults undergoing lumbar spinal fusion surgery include advanced age, diabetes, lower preoperative and postoperative hemoglobin, higher ASA grade, greater extent of surgery, and higher postoperative pain scores. Patients with delirium had a higher incidence of postoperative ICU admission, increased length of stay, decreased likelihood of discharge to home and increased mortality, all consistent with prior studies. Further studies may determine whether adequate management of anemia and pain lead to a reduction in the incidence of postoperative delirium in these patients.

Bone flap management strategies for postcraniotomy surgical site infection.

BACKGROUND: Surgical site infection (SSI) after a craniotomy is traditionally treated with wound debridement and disposal of the bone flap, followed by intravenous antibiotics. The goal of this study is to evaluate the safety of replacing the bone flap or performing immediate titanium cranioplasty. METHODS: All craniotomies at single center between 2008 and 2020 were examined to identify 35 patients with postoperative SSI. Patients were grouped by bone flap management: craniectomy (22 patients), bone flap replacement (seven patients), and titanium cranioplasty (six patients). Retrospective chart review was performed to identify patient age, gender, index surgery indication and duration, diffusion restriction on MRI, presence of gross purulence, bacteria cultured, sinus involvement, implants used during surgery, and antibiotic prophylaxis/ treatment. These variables were compared to future infection recurrence and wound breakdown. RESULTS: There was no significant difference in infection recurrence or future wound breakdown among the three bone flap management groups (P = 0.21, P = 0.25). None of the variables investigated had any significant relation to infection recurrence when all patients were included in the analysis. However, when only the bone flap replacement group was analyzed, there was significantly higher infection recurrence when there was frank purulence present (P = 0.048). CONCLUSION: Replacing the bone flap or performing an immediate titanium cranioplasty is safe alternatives to discarding the bone flap after postoperative craniotomy SSI. When there is gross purulence present, caution should be used in replacing the bone flap, as infection recurrence is significantly higher in this subgroup of patients.

Venous anatomy of the infratentorial compartment.

Approximately 7%-12% of all intracranial meningiomas are located in the posterior fossa (PF), a region which contains-among many other critical neurovascular structures-numerous major veins and sinuses draining blood away from the PF structures. There is a growing body of evidence indicating that venous sacrifice or injury during surgery are linked to serious postoperative complications-which may lead to significant morbidity and mortality. Thus, it is of paramount importance that clinicians charged with the preoperative, surgical, and postoperative care of patients undergoing treatment for meningioma are familiar with the general anatomy of the PF veins, as well as their structural nuances and drainage variations. The present chapter surveys the relevant anatomy in a manner that aims to be useful for an interdisciplinary team of clinicians and concludes with a discussion of emerging imaging technologies that may assist them in their clinical decision-making.

Endoscopic Transanterior Middle Temporal Approach to the Atrium-An Anatomical Feasibility Study.

OBJECTIVE: The atrium is the most common location for masses in the lateral ventricle. However, access to this area is limited owing to its deep location and adjacent eloquent neurovascular structures, such as the choroidal arteries, perisylvian white matter (WM) tracts, and optic radiations. We investigated the feasibility and safety of an endoscopic approach to the atrium via the anterior middle temporal gyrus (MTG). METHODS: Radiological assessment of a minimally invasive surgical trajectory to the atrium was achieved in 10 patients. Surgical simulation to assess the feasibility of our endoscopic approach was performed on 24 cadaveric specimens using a transzygomatic corridor and temporal craniotomy. Preoperative computed tomography was performed to confirm the surgical trajectory using neuronavigation. Using Klinger's method, 5 hemispheres were dissected to assess the relationship of our approach to the WM tracts. RESULTS: The optimal entry angle to reach the atrium through the anterior MTG was related to the temporal horn in the axial plane and to the Sylvian fissure in the sagittal plane. Our entry point in the anterior MTG was 19 ± 1.92 mm from the temporal pole. The transparenchymal distance to atrium was 24.55 ± 4.3 mm. The WM dissections confirmed that our approach did not violate the optic radiations, uncinate fasciculus, inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, or superior longitudinal fasciculus. CONCLUSION: Our findings have confirmed the feasibility of an anterior endoscopic approach to the atrium through the anterior MTG, with preservation of the functional integrity of the eloquent cortex and WM tracts.

Immersive Surgical Anatomy of the Frontotemporal-Orbitozygomatic Approach.

The frontotemporal-orbitozygomatic (FTOZ) approach is widely used for accessing anterolateral lesions in skull base surgery. Many studies have described the technique and quantified the surgical exposure and freedom provided by the FTOZ approach. However, few studies have provided a detailed analysis of the technique and surgical landmarks using three-dimensional (3D) models. In this study, we aimed to create a collection of volumetric models (VMs) and stereoscopic media on the step-by-step surgical technique of the FTOZ approach using cadaveric dissections. The FTOZ approach was divided into eight major steps: positioning, incision of the skin, dissection of scalp flap, mobilization of the temporalis muscle, dissection of periorbita, craniotomy, drilling of basal structures, and dural opening. The MacCarty keyhole and inferior orbital fissure are major surgical landmarks that were referenced for the six bony cuts. Photogrammetry and structured light scanning were used to construct high-resolution VMs. We illustrated the two-piece FTOZ craniotomy, followed by the one-piece and three-piece FTOZ craniotomies. Stereoscopic images, videos, and VMs were produced for each step of the surgical procedure. In addition, the mini-orbitozygomatic (MOz) and orbitopterional (OPt) approaches were considered and described as possible alternatives to the FTOZ approach. Recent advances in 3D technology can be implemented in neurosurgical practice to further enhance our spatial understanding of neurovascular structures. Surgical approaches should be carefully selected and tailored according to the patient's unique pathology and needs.