Comparison of Surgical Outcomes and Recurrence Rates of Cystic and Solid Vestibular Schwannomas.

Objective Cystic vestibular schwannomas (CVSs) are anecdotally believed to have worse clinical and tumor-control outcomes than solid vestibular schwannomas (SVSs); however, no data have been reported to support this belief. In this study, we characterize the clinical outcomes of patients with CVSs versus those with SVSs. Design This is a retrospective review of prospectively collected data. Setting This study is set at single high-volume neurosurgical institute. Participants We queried a database for details on all patients diagnosed with vestibular schwannomas between January 2009 and January 2014. Main Outcome Measures Records were retrospectively reviewed and analyzed using univariate and multivariate analyses to study the differences in clinical outcomes and tumor progression or recurrence. Results Of a total of 112 tumors, 24% ( n = 27) were CVSs and 76% ( n = 85) were SVSs. Univariate analysis identified the extent of resection, Koos grade, and tumor diameter as significant predictors of recurrence ( p ≤ 0.005). However, tumor diameter was the only significant predictor of recurrence in the multivariate analysis ( p = 0.007). Cystic change was not a predictor of recurrence in the univariate or multivariate analysis ( p ≥ 0.40). Postoperative facial nerve and hearing outcomes were similar for both CVSs and SVSs ( p ≥ 0.47). Conclusion Postoperative facial nerve outcome, hearing, tumor progression, and recurrence are similar for patients with CVSs and SVSs. As CVS growth patterns and responses to radiation are unpredictable, we favor microsurgical resection over radiosurgery as the initial treatment. Our data do not support the commonly held belief that cystic tumors behave more aggressively than solid tumors or are associated with increased postoperative facial nerve deficits.

Great Hospitals in North America: The Medical College of Wisconsin Neurological Surgery.

The Medical College of Wisconsin Department of Neurosurgery delivers subspecialty adult and pediatric neurosurgical care that is patient-centered, evidence-informed, and value-based. Medical College of Wisconsin research advances the science of neurological disease with the goal of a positive translational effect on clinical care. The department supports an environment of education and scholarship for trainees, faculty, and staff alike. The journey to become a neurosurgical center of excellence was accomplished with the leadership and foresight of the men and women who turned their dreams into reality. The establishment and rise of the department as a national force for neurosurgery and spine is an elegant example of the combination of individual leadership and foresight with synergistic institutional support.

A Rare Extra-Axial Midline Tentorial Adult Medulloblastoma with Dural-Tail Sign Mimicking a Meningioma.

Medulloblastomas are categorized as the World Health Organization Grade IV neoplasms. Only 33 cases have been reported of extra-axial, mostly in the cerebellar pontine angle and lateral cerebellar hemisphere, medulloblastomas in the current literature. Our study showcases the first case of an extremely rare presentation of an extra-axial midline tentorial adult medulloblastoma with the dural-tail sign mimicking a meningioma. To achieve the best possible outcome, a high index of suspicion for medulloblastoma is critical especially in young patient with an atypical posterior fossa mass as treatment regimens drastically different between a medulloblastoma and a meningioma.

Acid ceramidase is a novel drug target for pediatric brain tumors.

Pediatric brain tumors are the most common solid tumors in children and are also a leading culprit of cancer-related fatalities in children. Pediatric brain tumors remain hard to treat. In this study, we demonstrated that medulloblastoma, pediatric glioblastoma, and atypical teratoid rhabdoid tumors express significant levels of acid ceramidase, where levels are highest in the radioresistant tumors, suggesting that acid ceramidase may confer radioresistance. More importantly, we also showed that acid ceramidase inhibitors are highly effective at targeting these pediatric brain tumors with low IC50 values (4.6-50 µM). This data suggests acid ceramidase as a novel drug target for adjuvant pediatric brain tumor therapies. Of these acid ceramidase inhibitors, carmofur has seen clinical use in Japan since 1981 for colorectal cancers and is a promising drug to undergo further animal studies and subsequently a clinical trial as a treatment for pediatric patients with brain tumors.

A 5-Year Retrospective Analysis of Exposure to Ionizing Radiation by Neurosurgery Residents in the Modern Era.

BACKGROUND: The potential for radiation exposure during neurosurgical training has increased dramatically in the last decade. Incorporation of instrumented and minimally invasive spinal surgery and neuroendovascular procedures into the curriculum has led to increased potential for exposure to ionizing radiation. Contemporary neurosurgery residents' exposure to radiation has not been previously reported. OBJECTIVE: To determine neurosurgery residents' exposure to radiation over the course of 7 years of training. METHODS: Retrospective analysis of a prospectively maintained radiation database from July 2009 to July 2014 for all neurosurgery residents based on radiation dosimetry data. Standard radiation safety precautions were used (e.g., lead gowns or aprons), although compliance was not specifically monitored. RESULTS: Thirty-eight neurosurgery residents were monitored from 2009 to 2014. Radiation exposure data were available for 34 residents for the final analysis. A total of 20,541 days of radiation monitoring data were available. The mean deep dose equivalent over this period was 0.67 ± 0.75 mrem per resident/day. The calculated maximum cumulative exposure during the course of residency training was 12.15 ± 13.50 mSv, approximately equivalent to 6 computed tomography head scans. CONCLUSIONS: To our knowledge, this study is the first to quantify radiation exposure for neurosurgery residents in the current era of training. From this work, efforts may be initiated to increase awareness and safety with regard to radiation exposure. Although the total dose is not high, a better understanding of the impact of radiation exposure on practitioners may help to drive institutional policies to reduce occupational exposure.

Radiation Necrosis Secondary to Trigeminal Nerve TomoTherapy: A Cautionary Case Study.

New radiation delivery modalities have recently challenged Gamma Knife surgery as the historic gold standard in the treatment of trigeminal neuralgia (TN). TomoTherapy, a relative newcomer, has been approved by the U.S. FDA for various intracranial pathologies but is currently off label for the treatment of TN. A 73-year-old female presented with gait instability, intermittent headaches, and confusion. She was treated with TomoTherapy for refractory TN at an outside facility, which failed to reduce her symptoms. Magnetic resonance imaging demonstrated a lesion in the right mesial temporal lobe. A standard right anterior temporal lobectomy was performed and the final pathological report was notable for necrosis, gliosis, and edema consistent with a remote radiation injury. The patient improved postoperatively, but at her two-year follow up, she continued to have persistent bilateral TN and new onset seizures. Imaging revealed no new mass in the resection field. Stereotactic radiosurgery (SRS) is an evolving field with broadening indications, which makes it ever more important for physicians to be aware of differences between various SRS modalities. This case report highlights a cautionary example, and emphasizes the need for a more systematic evaluation of novel SRS methods before clinical application.

Surgical and clinical efficacy of sacroiliac joint fusion: a systematic review of the literature.

OBJECT: The sacroiliac joint (SIJ) and surgical intervention for treating SIJ pain or dysfunction has been a topic of much debate in recent years. There has been a resurgence in the implication of this joint as the pain generator for many patients experiencing low-back pain, and new surgical methods are gaining popularity within both the orthopedic and neurosurgical fields. There is no universally accepted gold standard for diagnosing or surgically treating SIJ pain. The authors systematically reviewed studies on SIJ fusion in the neurosurgical and orthopedic literature to investigate whether sufficient evidence exists to support its use. METHODS: A literature search was performed using MEDLINE, Google Scholar, and OvidSP-Wolters Kluwer Health for all articles regarding SIJ fusion published from 2000 to 2014. Original, peer-reviewed, prospective or retrospective scientific papers with at least 2 patients were included in the study. Exclusion criteria included follow-up shorter than 1-year, nonsurgical treatment, inadequate clinical data as determined by 2 independent reviewers, non-English manuscripts, and nonhuman subjects. RESULTS: A total of 16 peer-reviewed journal articles met the inclusion criteria: 5 consecutive case series, 8 retrospective studies, and 3 prospective cohort studies. A total of 430 patients were included, of whom 131 underwent open surgery and 299 underwent minimally invasive surgery (MIS) for SIJ fusion. The mean duration of follow-up was 60 months for open surgery and 21 months for MIS. SIJ degeneration/arthrosis was the most common pathology among patients undergoing surgical intervention (present in 257 patients [59.8%]), followed by SIJ dysfunction (79 [18.4%]), postpartum instability (31 [7.2%]), posttraumatic (28 [6.5%]), idiopathic (25 [5.8%]), pathological fractures (6 [1.4%]), and HLA-B27+/rheumatoid arthritis (4 [0.9%]). Radiographically confirmed fusion rates were 20%-90% for open surgery and 13%-100% for MIS. Rates of excellent satisfaction, determined by pain reduction, function, and quality of life, ranged from 18% to 100% with a mean of 54% in open surgical cases. For MIS patients, excellent outcome, judged by patients' stated satisfaction with the surgery, ranged from 56% to 100% (mean 84%). The reoperation rate after open surgery ranged from 0% to 65% (mean 15%). Reoperation rate after MIS ranged from 0% to 17% (mean 6%). Major complication rates ranged from 5% to 20%, with 1 study that addressed safety reporting a 56% adverse event rate. CONCLUSIONS: Surgical intervention for SIJ pain is beneficial in a subset of patients. However, with the difficulty in accurate diagnosis and evidence for the efficacy of SIJ fusion itself lacking, serious consideration of the cause of pain and alternative treatments should be given before performing the operation.

Long-term functional outcomes and predictors of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms in the BRAT trial: revisiting the clip vs coil debate.

BACKGROUND: Acute hydrocephalus is a well-known sequela of aneurysmal subarachnoid hemorrhage (SAH). Controversy exists about whether open microsurgical methods serve to reduce shunt dependency compared with endovascular techniques. OBJECTIVE: To determine predictors of shunt-dependent hydrocephalus and functional outcomes after aneurysmal SAH. METHODS: A total of 471 patients who were part of a prospective, randomized, controlled trial from 2003 to 2007 were retrospectively reviewed. All variables including demographic data, medical history, treatment, imaging, and functional outcomes were included as part of the trial. No additional variables were retrospectively collected. RESULTS: Ultimately, 147 patients (31.2%) required a ventriculoperitoneal shunt (VPS) in our series. Age, dissecting aneurysm type, ruptured vertebrobasilar aneurysm, Fisher grade, Hunt and Hess grade, admission intraventricular hemorrhage, admission intraparenchymal hemorrhage, blood in the fourth ventricle on admission, perioperative ventriculostomy, and hemicraniectomy were significant risk factors (P < .05) associated with shunt-dependent hydrocephalus on univariate analysis. On multivariate analysis, intraventricular hemorrhage and intraparenchymal hemorrhage were independent risk factors for shunt dependency (P < .05). Clipping vs coiling treatment was not statistically associated with VPS after SAH on both univariate and multivariate analyses. Patients who did not receive a VPS at discharge had higher Glasgow Outcome Scale and Barthel Index scores and were more likely to be functionally independent and to return to work 72 months after surgery (P < .05). CONCLUSION: There is no difference in shunt dependency after SAH among patients treated by endovascular or microsurgical means. Patients in whom shunt-dependent hydrocephalus does not develop after SAH tend to have improved long-term functional outcomes.