Open-door extended endoscopic transorbital technique to the paramedian anterior and middle cranial fossae: technical notes, anatomomorphometric quantitative analysis, and illustrative case.

OBJECTIVE: The superior eyelid endoscopic transorbital approach (SETOA) provides a direct and short minimally invasive route to the anterior and middle skull base. Nevertheless, it uses a narrow corridor that limits its angles of attack. The aim of this study was to evaluate the feasibility and potential benefits of an "extended" conservative variant of the "standard" endoscopic transorbital approach-termed "open-door"-to enhance the exposure of lesions affecting the paramedian aspect of the anterior and middle cranial fossae. METHODS: First, the authors described the technical nuances of the open-door extended transorbital approach (ODETA). Next, they documented its morphometric advantages over standard SETOA. Finally, they provided a clinical-anatomical application to demonstrate enhanced exposure and better angles of attack to treat lesions occupying the paramedian anterior and middle cranial fossae. Five adult cadaveric specimens (10 sides) initially underwent standard SETOA and then extended open-door SETOA (ODETA to the paramedian anterior and middle fossae). The adjunct of hinge-orbitotomy, through three surgical steps and straddling the frontozygomatic suture, converted conventional SETOA to its extended open-door variant. CT scans were performed before dissection and uploaded to the neuronavigation system for quantitative analysis. The angles of attack on the axial plane that addressed four key landmarks, namely the tip of the anterior clinoid process (ACP), foramen rotundum (FR), foramen ovale (FO), and trigeminal impression (TI), were calculated for both operative techniques and compared. RESULTS: Hinge-orbitotomy of the extended open-door SETOA resulted in several surgical, functional, and esthetic advantages: it provided wider axial angles of attack for each of the target points, with a gain angle of 26.68° ± 1.31° for addressing the ACP (p < 0.001), 29.50° ± 2.46° for addressing the FR (p < 0.001), 19.86° ± 1.98° for addressing the FO (p < 0.001), and 17.44° ± 2.21° for addressing the lateral aspect of the TI (p < 0.001), while hiding the skin scar, avoiding temporalis muscle dissection, preserving flap vascularization, and decreasing the rate of bone infection and degree of orbital content retraction. CONCLUSIONS: The extended open-door technique may be specifically suited for selected patients affected by paramedian anterior and middle fossae lesions, with prevalent anteromedial extension toward the anterior clinoid, the foremost compartment of the cavernous sinus and FR and not completely controlled with the pure endoscopic transorbital approach.

Minimally invasive trans-sulcal parafascicular surgical resection of cerebral tumors: translating anatomy to early clinical experience.

The minimally invasive port-based trans-sulcal parafascicular surgical corridor (TPSC) has incrementally evolved to provide a safe, feasible, and effective alternative to access subcortical and intraventricular pathologies. A detailed anatomical foundation is important in mitigating cortical and white matter tract injury with this corridor. Thus, the aims of this study are (1) to provide a detailed anatomical construct and overview of TPSCs and (2) to translate an anatomical framework to early clinical experience. Based on regional anatomical constraints, suitable parafascicular entry points were identified and described. Fiber tracts at both minimal and increased risks for each corridor were analyzed. TPSC-managed cases for metastatic or primary brain tumors were retrospectively reviewed. Adult patients 18 years or older with Karnofsky Performance Status (KPS) ≥ 70 were included. Subcortical brain metastases between 2 and 6 cm or primary brain tumors between 2 and 5 cm were included. Patient-specific corridors and trajectories were determined using MRI-tractography. Anatomy: The following TPSCs were described and translated to clinical practice: superior frontal, inferior frontal, inferior temporal, intraparietal, and postcentral sulci. Clinical: Eleven patients (5 males, 6 females) were included (mean age = 52 years). Seven tumors were metastatic, and 4 were primary. Gross total, near total, and subtotal resection was achieved in 7, 3, and 1 patient(s), respectively. Three patients developed intraoperative complications; all recovered from their intraoperative deficits and returned to baseline in 30 days. A detailed TPSC anatomical framework is critical in conducting safe and effective port-based surgical access. This review may represent one of the few early translational TPSC studies bridging anatomical data to clinical subcortical and intraventricular surgical practice.

Initial experience with a robotically operated video optical telescopic-microscope in cranial neurosurgery: feasibility, safety, and clinical applications.

OBJECTIVE The move toward better, more effective optical visualization in the field of neurosurgery has been a focus of technological innovation. In this study, the authors' objectives are to describe the feasibility and safety of a new robotic optical platform, namely, the robotically operated video optical telescopic-microscope (ROVOT-m), in cranial microsurgical applications. METHODS A prospective database comprising patients who underwent a cranial procedure between April 2015 and September 2016 was queried, and the first 200 patients who met the inclusion criteria were selected as the cohort for a retrospective chart review. Only adults who underwent microsurgical procedures in which the ROVOT-m was used were considered for the study. Preoperative, intraoperative, and postoperative data were retrieved from electronic medical records. The authors address the feasibility and safety of the ROVOT-m by studying various intraoperative variables and by reporting perioperative morbidity and mortality, respectively. To assess the learning curve, cranial procedures were categorized into 6 progressively increasing complexity groups. The main categories of pathology were I) intracerebral hemorrhages (ICHs); II) intraaxial tumors involving noneloquent regions or noncomplex extraaxial tumors; III) intraaxial tumors involving eloquent regions; IV) skull base pathologies; V) intraventricular lesions; and VI) cerebrovascular lesions. In addition, the entire cohort was evenly divided into early and late cohorts. RESULTS The patient cohort comprised 104 female (52%) and 96 male (48%) patients with a mean age of 56.7 years. The most common pathological entities encountered were neoplastic lesions (153, 76.5%), followed by ICH (20, 10%). The distribution of cases by complexity categories was 11.5%, 36.5%, 22%, 20%, 3.5%, and 6.5% for Categories I, II, II, IV, V, and VI, respectively. In all 200 cases, the surgical goal was achieved without the need for intraoperative conversion. Overall, the authors encountered 3 (1.5%) major neurological morbidities and 6 (3%) 30-day mortalities. Four of the 6 deaths were in the ICH group, resulting in a 1% mortality rate for the remainder of the cohort when excluding these patients. None of the intraoperative complications were considered to be attributable to the visualization provided by the ROVOT-m. When comparing the early and late cohorts, the authors noticed an increase in the proportion of higher-complexity surgeries (Categories IV-VI), from 23% in the early cohort, to 37% in the late cohort (p = 0.030). In addition, a significant reduction in operating room setup time was demonstrated (p < 0.01). CONCLUSIONS The feasibility and safety of the ROVOT-m was demonstrated in a wide range of cranial microsurgical applications. The authors report a gradual increase in case complexity over time, representing an incremental acquisition of experience with this technology. A learning curve of both setup and execution phases should be anticipated by new adopters of the robot system. Further prospective studies are required to address the efficacy of ROVOT-m. This system may play a role in neurosurgery as an integrated platform that is applicable to a variety of cranial procedures.

Full endoscopic endonasal expanded approach to the petroclival region: optimizing the carotid-clival window.

BACKGROUND: The petroclival junction (PCJ) is a challenging skull base location from neurosurgical point of view, especially if the retrocarotid space has to be reached. METHOD: In response to this challenge, this report provides a detailed full description of the endoscopic endonasal expanded approach (EEA) to the petroclival region and retrocarotid space. We present the technique step by step, introducing a critical concept about the optimization of the petroclival drilling, generating the carotid-clival window (CCW). The CCW is delimited by the paraclival segment of the internal carotid artery ICA anterolaterally, the petrous bone posterolaterally, the clival dura medially, the synchondrosis inferiorly, and the cavernous sinus superiorly; therefore, this approach exposes an important nuance to augment the previous approaches for PCJ and retrocarotid space. CONCLUSION: This technique provides a good surgical window and carries minimal risk.

Intraoperative flash VEPs are reproducible in the presence of low amplitude EEG.

Flash visual evoked potentials (FVEPs) are often irreproducible during surgery. We assessed the relationship between intraoperative FVEP reproducibility and EEG amplitude. Left then right eyes were stimulated by goggle light emitting diodes, and FVEPs were recorded from Oz­Fz' (International 10-20 system) in 12 patients. Low cut filters were ≤5 Hz in all patients; two patients also had recordings using 10 and 30 Hz. The reproducibility of FVEP and the amplitude of the concomitant EEG from C4'­Fz were measured. Nine patients had low amplitude EEG (<30 µV); reproducible FVEPs were obtained from all eyes with normal pre-operative vision. The other three patients had high amplitude EEG (>50 µV); FVEPs were absent from three of four eyes with normal pre-operative vision (the other normal eye had a present but irreproducible FVEP). Raising the low cut filter to 10 and 30 Hz (in two patients) progressively reduced EEG and FVEP amplitude, reduced amplifier blocking time and improved FVEP reproducibility. FVEPs were more reproducible in the presence of low amplitude EEG than high amplitude EEG. This is the first report describing the effect of EEG amplitude on FVEP reproducibility during surgery

Evaluating soluble Axl as a biomarker for glioblastoma: A pilot study.

With current imaging, discriminating tumor progression from treatment effect following immunotherapy or oncolytic virotherapy of glioblastoma (GBM) is challenging. A blood based diagnostic biomarker would therefore be helpful. Axl is a receptor tyrosine kinase that is highly expressed by many cancers including GBM. Axl expression is regulated through enzymatic cleavage of its extracellular domain. The resulting fragment can be detected in serum as soluble Axl (sAxl). sAxl levels can distinguish patients with melanoma, hepatocellular carcinoma, and pancreatic ductal adenocarcinoma from healthy controls. This is a pilot study to determine if sAxl is a candidate biomarker for GBM. The sAxl levels in the serum of 40 healthy volunteers and 20 GBM patients were determined using an enzyme-linked immunosorbent assay (ELISA). Pre- and post- operative sAxl levels were obtained. Volumetric MRI evaluation provided GBM tumor volume metrics. There was no significant difference in the sAxl levels of the volunteers (30.16±1.88 ng/ml) and GBM patients (30.74±1.96 ng/ml) p = 0.27. The postoperative sAxl levels were significantly higher than preoperative levels (32.32±2.26 ng/ml vs 30.74±1.96 ng/ml, p = 0.03). We found no correlation between tumor volume and sAxl levels. Axl expression was low or absent in 6 of 11 (55%) patient derived GBM cell lines. Given the wide range of Axl expression by GBM tumors, sAxl may not be a reliable indicator of GBM. However, given the small sample size in this study, a larger study may be considered.

Diagnosis and treatment of chordoma.

Chordoma is a primary bone cancer arising on the midline from the skull base to the sacrum. Diagnosis is often delayed because of insidious onset and nonspecific symptoms. Chordomas appear histologically low-grade but are highly invasive and often recur locally. Management centers primarily on radical en bloc surgical resection when possible. Radiation therapy using protons and/or photons is often necessary because complete resection is seldom possible due to critical location and invasion of the cancer cells into surrounding structures. No approved medical therapy exists. The high rate of recurrence is reflected by a median survival of 6 to 7 years. This article reviews the clinical management of chordoma and discusses ongoing research in the field.

Minimal access to deep intracranial lesions using a serial dilatation technique: case-series and review of brain tubular retractor systems.

Surgical access to deep intracranial lesions causing the least amount of iatrogenic trauma to the surrounding brain tissue remains a challenging task. In this article, we evaluate the use of a set of sequential tubes that dilate and provide retraction of the overlying brain tissue acting as a surgical corridor for deep-seated brain lesions resection. In addition, we conducted a comprehensive review of the literature of previously described techniques using variable brain tubular retractor systems. We discuss the adaptation of a system designed for spinal use to intracranial pathologies and evaluate the outcomes for the patients involved in the study. Moreover, the advantages and limitations of the described technique were presented. Between August 2005 and 2011, a total of 30 patients with deep brain lesions were operated on using an incremental increase of tubing size for brain retraction guided by a frameless navigation device. Of these, seven cases were intraventricular, and 23 were intraparenchymal. Gross total resection was achieved in 70 % of cases, and the remaining had planned subtotal resections due to involvement of an eloquent area. In conclusion, the technique of serial dilatation of the brain tissue can be used in conjunction with a microscope or endoscope to provide satisfactory access to deep intracranial pathologies. It appears to minimize the associated retraction injury to the surrounding tissue by gradually dilating the white fiber tracts. This operative approach may be considered as an effective and safe alternative for brain tumor resections in selected cases, especially deep-seated lesions.

Associations Between Residential Greenspace, Socioeconomic Status, and Stroke: A Matched Case-Control Study.

Purpose: Studies have shown increased residential greenspace is associated with improved outcome following stroke. This study sought to determine if residential greenspace is an independent stroke risk factor. Methods: A retrospective 1:4 matched case-control study involving 1174 stroke and 4696 control patients over a 3-year period from Milwaukee County, Wisconsin, was conducted. Greenspace was determined using normalized difference vegetation index (NDVI) for a 250-meter radius surrounding a subject's residence. The area deprivation index (ADI) for the census block tract of a subject's residence was obtained from the Neighborhood Atlas® (University of Wisconsin School of Medicine and Public Health). Relationship between greenspace, ADI, and stroke was determined using conditional logistic regression. Relationships among NDVI, state and national ADI, and proximity to public parks were determined using Spearman's rank-order correlation. Results: NDVI and stroke risk were inversely correlated (odds ratio [OR]: 0.33, 95% CI: 0.111-0.975; P=0.045), with 19% lowered odds of stroke for patients living in the highest greenspace quartile compared to the lowest quartile (OR: 0.81, 95% CI: 0.672-0.984; P=0.045). Patients living in the most deprived ADI quartile had 28% greater stroke risk than those living in the least deprived ADI quartile (OR: 1.28, 95% CI: 1.02-1.6; P=0.029). Non-Hispanic Black patients lived in residential areas with lower greenspace (P<0.001) and neighborhoods of greater state and national ADI (P<0.001 for both) than non-Hispanic White patients. Conclusions: In Milwaukee County, living with greater surrounding greenspace or areas of lower deprivation is associated with lower odds of stroke. NDVI represents an independent risk factor for stroke, not simply a proxy for socioeconomic status.

Effect of botulinum neurotoxin treatment in the lateral spread monitoring of microvascular decompression for hemifacial spasm.

INTRODUCTION: Botulinum neurotoxin (BtNtx) treatment for hemifacial spasm (HFS) prior to microvascular decompression (MVD) is hypothesized to be a factor in the variability of intraoperative neurophysiological monitoring (IONM) during this procedure. METHODS: We analyzed 282 MVDs performed at the University of Pittsburgh Medical Center between January 1, 2000 and December 31, 2007. We retrospectively compared the lateral spread response (LSR) in the mentalis muscle when stimulus-triggered electromyography (EMG) was elicited from the facial nerve. Previous BtNtx treatment was the grouping factor. RESULTS: Baseline LSR amplitudes during MVD (prior BtNtx: mean = 341.47 µV; no BtNtx: mean = 241.81 µV) were significantly different between groups (df = 1,281; t = -2.463; P = 0.014). Comparisons of latency and current threshold at baseline, as well as HFS disappearance or LSR persistence after the procedure, did not achieve statistical significance. CONCLUSIONS: HFS patients treated with BtNtx prior to MVD demonstrated higher LSR baseline amplitudes during IONM. This could be related to muscle poly-reinnervation after recovery from repeated BtNtx use.

Management of Cushing's disease after failed surgery--a review.

Selective transsphenoidal adenomectomy is generally recommended for initial treatment of Cushing's disease (CD) because it achieves a high (70-85%) rate of remission. However, if initial surgery is not successful, the approach to persistent or recurrent CD is more complex. Because residual or recurrent adenoma is typically found at the site of the original adenoma, repeat transsphenoidal surgery is recommended including selective adenomectomy, hemihypophysectomy or total hypophysectomy. If repeat pituitary surgery does not achieve remission, then possible adjuvant therapies include radiosurgery or stereotactic radiotherapy, bilateral adrenalectomy, and/or medical therapy. In all cases of persistent or recurrent CD, successful treatment requires close collaboration of endocrinologists, radiation oncologists and neurosurgeons.

Role of endothelin-1 in human aneurysmal subarachnoid hemorrhage: associations with vasospasm and delayed cerebral ischemia.

BACKGROUND: Endothelin-1 (ET-1) is a potent vasoconstrictor implicated in the pathogenesis of vasospasm and delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients. The aim of this study was to investigate the relationship between cerebrospinal fluid (CSF) ET-1 levels and angiographic vasospasm and DCI. METHODS: Patients with aSAH were consented (n = 106). Cerebral vasospasm was determined by angiography. DCI was determined by transcranial Doppler (TCD) results and/or angiogram results with corresponding clinical deterioration. CSF ET-1 levels over 14 days after the initial insult was quantified by ELISA. ET-1 analysis included a group-based trajectory analysis and ET-1 exposure rate during 24, 48, and 72 h prior to, as well as 72 h post angiography, or clinical deterioration. RESULTS: Trajectory analysis revealed two distinct groups of subjects with 56% of patients in the low ET-1 trajectory group (mean at day 1 = 0.31 pg/ml; SE = 0.04; mean at day 14 = 0.41 pg/ml; SE = 0.15) and 44% of patients in the high ET-1 trajectory group (mean at day 1 = 0.65 pg/ml; SE = 0.08; mean at day 14 = 0.61 pg/ml; SE = 0.06). Furthermore, we observed that ET-1 exposure rate 72 h before angiography and clinical spasm was a significant predictor of both angiographic vasospasm and DCI, whereas, ET-1 exposure after angiography and clinical spasm was not associated with either angiographic vasospasm or DCI. CONCLUSION: Based on these results we conclude that ET-1 concentrations are elevated in a sub-group of patients and that the acute (72 h prior to angiography and clinical neurological deterioration), but not chronic, elevations in CSF ET-1 concentrations are indicative of the pathogenic alterations of vasospasm and DCI in aSAH patients.

Microsurgical anatomy of the cranial nerve-centric triangles of the posterior cranial base: cadaveric and radiological anatomical study.

Tumors in the posterior fossa can be situated either dorsal and lateral, ventral and medial, or occupying both regions in relation to the cranial nerves, with the latter position being especially challenging. In an effort to organize neurovascular complexes contained within, anatomically based triangles have been proposed to serve as guiding landmarks for locating critical neurovascular structures. The objectives of this study were to: (1) provide a review of historical anatomically based vascular-centric triangles of the posterior fossa based on respective neurovascular complexes; (2) introduce a more organized alternative system of triangles with the conceptualization of a projection system from superficial to deep; and (3) propose and describe two new triangles of the posterior fossa: Petrous-Acousticofacial and Acousticofacial-Trigeminal. Five cadavers were studied. Neurovascular complexes were described with the use of anatomically guided cranial nerve-centric triangles, each of which was formed by cranial nerves, petrous bone, brainstem, tentorium, and superior petrosal vein. All triangles were measured and anatomical boundaries confirmed by neuronavigation. Two circumferential frameworks were created to correlate superficial and deep anatomy: (1) Outer circumference and (2) Inner circumference. Posterior fossa was divided into the following: (1) Superior complex-corresponds to the sub-asterional region, which was projected to the trigeminal nerve; (2) Middle complex-corresponds to the mastoid emissary vein foramen, which was projected to the facial and vestibulocochlear nerves; and (3) Inferior complex-corresponds to the posterior condylar canal, which projects to the lower cranial nerves. Neuronavigation confirmed these landmarks. Two new triangles were proposed: (1) The Petrous-Acousticofacial triangle, and (2) The Acousticofacial-Trigeminal triangle. Triangles provide a useful anatomical guide to the posterior fossa. We have introduced an organized schema, as well as proposed two new triangles, with the intent to minimize manipulation of neurovascular structures.

AXL receptor is required for Zika virus strain MR-766 infection in human glioblastoma cell lines.

Recent reports have shown that Zika virus (ZIKV) has oncolytic potential against human glioblastoma (GBM); however, the mechanisms underlying its tropism and cell entry are not completely understood. The receptor tyrosine kinase AXL has been identified as an entry receptor for ZIKV in a cell-type-specific manner. Interestingly, AXL is frequently overexpressed in GBM patients. Using commercially available GBM cell lines, we first show that cells expressing AXL are permissive for ZIKV infection, while cells that do not express AXL are not. Furthermore, inhibition of AXL kinase using R428 and antibody blockade of AXL receptor strongly attenuated virus entry in GBM cell lines. Additionally, CRISPR knockout of the AXL gene in GBM cell lines completely abolished ZIKV infection, significantly inhibited viral replication, and significantly reduced apoptosis compared with parental lines. Lastly, introduction of AXL receptor into non-expressing cell lines renders the cells susceptible to ZIKV infection. Together, these findings demonstrate that ZIKV entry into GBM cells in vitro is mediated by the AXL receptor and that following cell entry, productive infection is cytotoxic. Thus, ZIKV is a potential oncolytic virus for GBM.

Endonasal Odontoidectomy in Basilar Invagination.

Objective The endoscopic endonasal odontoidectomy (EEO) is emerging as a feasible surgical alternative to conventional microscopic transoral approach. In this article, we show EEO in the basilar invagination (BI) and describe in detail the technical aspects, advantages, and disadvantages of this approach ( Fig. 1 ). Methods We describe EEO using audiovisual material from the neurosurgical department of Hospital Universitari i Politècnic La Fe Valencia database. Results We present the case of a 61-year-old male patient with BI. Initially, we performed suboccipital decompression and occipitocervical fusion. Subsequently, after a no significant neurological improvement and persistent anterior compression, EEO was performed. The postoperative evolution was uneventful and the preoperative neurological deficits were recovered rapidly after surgery Discussion EEO technique enables complete odontoid resection, preventing invasion of aggressive oral bacterial flora, and it is not limited by the mouth opening. As well, it avoids manipulation of the soft palate, therefore evades the risk of velopalatal insufficiency, facilitates immediate oral tolerance, and early extubation. The rostral position of C1-C2 complex in BI could suppose a great advantage in favor the endonasal approaches. Mucoperichondrial vascularized flaps could be obtained to avoid a postoperative cerebrospinal fluid (CSF) leak and facilitate the reepithelization process of the surgical bed. Conclusion EEO may provide a significant anatomic and technical advantage over the trans-oral approach. The link to the video can be found at: https://youtu.be/Td6MDcjCNKk .

The Role of 3D Tractography in Skull Base Surgery: Technological Advances, Feasibility, and Early Clinical Assessment with Anterior Skull Base Meningiomas.

Objective The aim of this study is to determine feasibility of incorporating three-dimensional (3D) tractography into routine skull base surgery planning and analyze our early clinical experience in a subset of anterior cranial base meningiomas (ACM). Methods Ninety-nine skull base endonasal and transcranial procedures were planned in 94 patients and retrospectively reviewed with a further analysis of the ACM subset. Main Outcome Measures (1) Automated generation of 3D tractography; (2) co-registration 3D tractography with computed tomography (CT), CT angiography (CTA), and magnetic resonance imaging (MRI); and (3) demonstration of real-time manipulation of 3D tractography intraoperatively. ACM subset: (1) pre- and postoperative cranial nerve function, (2) qualitative assessment of white matter tract preservation, and (3) frontal lobe fluid-attenuated inversion recovery (FLAIR) signal abnormality. Results Automated 3D tractography, with MRI, CT, and CTA overlay, was produced in all cases and was available intraoperatively. ACM subset : 8 (44%) procedures were performed via a ventral endoscopic endonasal approach (EEA) corridor and 12 (56%) via a dorsal anteromedial (DAM) transcranial corridor. Four cases (olfactory groove meningiomas) were managed with a combined, staged approach using ventral EEA and dorsal transcranial corridors. Average tumor volume reduction was 90.3 ± 15.0. Average FLAIR signal change was -30.9% ± 58.6. 11/12 (92%) patients (DAM subgroup) demonstrated preservation of, or improvement in, inferior fronto-occipital fasciculus volume. Functional cranial nerve recovery was 89% (all cases). Conclusion It is feasible to incorporate 3D tractography into the skull base surgical armamentarium. The utility of this tool in improving outcomes will require further study.

The transclival endoscopic endonasal approach (EEA) for prepontine neuroenteric cysts: report of two cases.

INTRODUCTION: The transclival endoscopic endonasal approach was used to completely remove a prepontine neuroenteric cyst in two different patients. CASE REPORTS: Full clinical improvement without postoperative complication was achieved in both cases. The postoperative hospital stay was limited to 2 and 3 days. DISCUSSION: In comparison to posterolateral skull base approaches, the transclival endoscopic endonasal approach allows direct access to the prepontine cistern without unnecessary manipulation of neurovascular structures at the cerebellopontine angle. In contrast to transoral surgery, patients may have decreased risk of infection and can be fed orally immediately without the risks of palatal and oropharyngeal dehiscence. CONCLUSION: Neuronavigation technology, strict adherence to microsurgical principles, and significant endoneurosurgical experience are strongly recommended when approaching these challenging lesions.

Epidemiology of male breast cancer.

BACKGROUND: Due to its rarity, few studies have characterized the epidemiology of male breast cancer. The purpose of this study was to determine survival and risk factors for male breast cancer in a large U.S. METHODS: In this study, 19,795 male patients with breast cancer were identified from the National Cancer Database (2004-2014). Patient demographics, tumor characteristics and treatments were analyzed by using descriptive statistics. We used multivariate Cox regression and Kaplan Meier analysis. RESULTS: Over 10 years, the incidence of male breast cancer increased from 7.2% to 10.3%, while mortality decreased from 11% to 3.8%. Socioeconomic factors predicting mortality included income medium, and high vs low (HR = 0.78; 0.68), private vs no insurance (HR = 0.73) and the academic research facility vs community cancer center (HR = 0.79). Significant predictors of all-cause mortality included age (HR = 1.04), tumor size (HR = 1.01), hormone receptor expression (HR = 0.8) and cancer stage I vs II, III, and IV at the time of diagnosis (HR = 1.5, 2.7, 4.4, 9.9 respectively). Other predictors of mortality include surgery (HR = 0.4), chemotherapy (HR = 0.8), radiation (HR = 0.8), and hormonal therapy (HR-0.8). CONCLUSIONS: Socioeconomic factors, cancer stage, tumor characteristics (size and grade), and high Charlson-Dayo score contributed to higher mortality among male patients diagnosed with breast cancer. Surgery was most effective, followed by radiation, chemotherapy, and hormonal therapy. Patients with positive ER or PR expression demonstrated better survival. Adjusting for socioeconomic factors, biomarker identification and timely, appropriately chosen treatment are likely to reduce the risk for mortality.

A Feasibility Study of Lavender Aromatherapy in an Awake Craniotomy Environment.

PURPOSE: Integrative medicine interventions are needed for awake craniotomies, as many patients experience anxiety. Lavender aromatherapy significantly reduces anxiety or pain in a variety of surgical procedures. This feasibility study used lavender aromatherapy during awake craniotomies to determine the number of patients who would consent and complete the study, the technicality of lavender aromatherapy use, and acceptance by operating room (OR) staff. METHODS: We approached 40 consecutive patients (≥18 years old). Exclusion criteria were pulmonary issues or sensitivity to lavender. Outcome measures in consented patients were enrollment and completion rates, anxiety and pain as measured by the Visual Analog Scale for Anxiety (VAS-A) and Visual Analog Scale for Pain (VAS-P), and satisfaction with pain control using the Patient Opinion of Pain Management (POPM) survey. RESULTS: Of the 40 patients approached, 4 declined participation or had their surgery cancelled. Of the remaining 36, 4 required increased sedation during surgery and 1 was unable to detect lavender. Thus, 31 patients (77.5%) completed the study. VAS-A and VAS-P scores trended lower after lavender inhalation, but the difference did not reach statistical significance. There was a slight increase in VAS-P score at the OR1 time point. Expectancy for reduction in both anxiety and pain were not significantly different. Improvement in anxiety also was not different, while improvement in pain trended lower (P=0.025). POPM results indicated the majority of patients were either "satisfied" or "very satisfied" with pain management. CONCLUSIONS: This study demonstrated 77.5% completion and the ability to integrate lavender aromatherapy into the OR. Thus, we plan to conduct a randomized clinical trial to assess efficacy of lavender aromatherapy.