Superior semicircular canal dehiscence postoperative outcomes: a case series of 350 repairs.

BACKGROUND: Superior Semicircular Canal Dehiscence (SSCD) is a dehiscence of the otic capsule which normally lies over the superior semicircular canal. This database constitutes the largest series of SSCD patients to date. OBJECTIVE: To determine what preoperative factors, if any, contribute to postoperative outcomes and evaluate symptom resolution in a large SSCD patient cohort. METHODS: A single-institution, retrospective chart review collected patient demographics, intraoperative findings, and pre-and postoperative symptoms. Fisher's exact t-test was performed for unpaired categorical variables, with a significance level of p < 0.05. RESULTS: 350 SSCD repairs were performed. The median age was 52 years (range: 17-86 years, ± 6.4 years), and the median follow-up duration was 4.6 months (range: 0.03-59.5 months, ± 6.8 months). Preoperative hearing loss was significantly associated with female sex (p = 0.0028). The most reported preoperative symptoms were tinnitus (77.4%), dizziness (74.0%), autophony (66.3%), amplification (63.7%), and disequilibrium (62.6%). Between patients who received unilateral versus bilateral SSCD repair, the greatest postoperative symptomatic resolution was seen in autophony (74.9%, p < 0.001), amplification (77.3%, p = 0.00027), hyperacusis (77.4%, p = 0.023), hearing (62.9%, p = 0.0063), and dizziness (54.6%, p < 0.001) for patients with unilateral SSCD repair. CONCLUSION: Surgical repair via the middle cranial fossa approach can significantly resolve auditory, vestibular, and neurological symptoms of patients with SSCD. Although this is one of the largest single-institution SSCD studies to date, future multi-institutional, prospective studies would be beneficial to validate these results.

Preoperative meningioma vascularity index is associated with significantly increased intraoperative blood loss and greater risk of subtotal resection.

OBJECTIVE: Surgical recovery of meningiomas relies on a variety of factors, including tumor volume, vascularity, embolization status, and blood loss during excision. Although hypervascular meningiomas can potentially be amendable to embolization, methods for determining optimal vascularity for this procedure are currently lacking. Our group previously established the meningioma vascularity index (MVI) as a marker of tumor vascularity. In this study, we aim to build on our previous work and further examine the relationship between MVI and intraoperative estimated blood loss (EBL). METHODS: A retrospective data extraction was conducted between August 2010 and October 2019 from patients undergoing craniotomy for meningioma. Of the 85 intracranial meningiomas included, 39 were embolized. Demographic data, extent of resection, embolization status, and EBL were among the extracted variables. Flow void volumes were measured on T2-weighted MRI images using a segmentation software with a voxel-based segmentation method. RESULTS: MVI was a predictor of EBL within the entire cohort, when controlling for tumor volume (R2 adjusted = 0.26; P = 0.027). A high MVI (> 2.01 cm3) was associated with higher likelihood of receiving subtotal resection (STR) (OR 4.07, 95% CI 1.17-14.15; P = 0.035). Although the mean MVI and tumor volume were higher in the embolized cohort (P = 0.009 and P = 0.005), there were no significant differences in EBL, or blood transfusion rates regardless of embolization status. CONCLUSIONS: MVI may be used as a non-invasive radiological marker to gauge meningioma vascularity, predict EBL, and guide the decision-making process when it comes to embolization and surgical planning.

Meta-analysis of adjuvant radiotherapy for intracranial atypical and malignant meningiomas.

INTRODUCTION: Meningiomas comprise 33% of all CNS tumors. The World Health Organization (WHO) describes meningiomas as benign (BM), atypical (AM), and malignant/anaplastic (MM). High-grade meningiomas such as AMs and MMs are more aggressive, recur more frequently, and portend a worse prognosis than BMs. Currently, the standard treatment for high-grade meningiomas, especially AMs, is ill-defined. In particular, the benefit to survival outcomes of adjuvant radiotherapy post-surgical resection remains unclear. In this study, we investigated the effect of adjuvant radiotherapy (ART) post-surgery on survival outcomes compared to surgery alone for high-grade meningiomas. METHODS: PRISMA guidelines were a foundation for our literature review. We screened the PubMed database for studies reporting overall survival (OS), progression free survival (PFS), and tumor recurrence for intracranial, primary AM and MMs treated with surgery+ART or surgery alone. Fixed and random effect models compared tumor control rate for AM aforementioned groups. RESULTS: Mean 5-year PFS was 76.9% for AM (surgery+ART) and 55.9% for AM (surgery alone) patients. Mean 5-year OS was 81.3% and 74% for AM (surgery+ART) and AM (surgery alone) groups, respectively. Overall, the mean 5-year PFS for aggregated high-grade meningiomas AM+MM (surgery+ART) was 67.6%. Fixed effect models revealed tumor control rate as 76% for AM (surgery+ART) and 69% for AM (surgery alone) groups. ART induced toxicity incidence ranged from 12.0% to 35.5% for AM and MM patients. CONCLUSIONS: Our analysis suggests that (surgery+ART) may increase PFS, OS, and tumor control rates in high-grade meningiomas. However, further studies involving surgery+ ART should be conducted to fully evaluate the ideal radiosurgical candidate, modality, and dosage.

Radiotherapy versus combination radiotherapy-bevacizumab for the treatment of recurrent high-grade glioma: a systematic review.

BACKGROUND: High-grade gliomas (HGG) comprise the most common primary adult brain cancers and universally recur. Combination of re-irradiation therapy (reRT) and bevacizumab (BVZ) therapy for recurrent HGG is common, but its reported efficacy is mixed. OBJECTIVE: To assess clinical outcomes after reRT ± BVZ in recurrent HGG patients receiving stereotactic radiosurgery (SRS), hypofractionated radiosurgery (HFSRT), or fully fractionated radiotherapy (FFRT). METHODS: We performed a systematic review of PubMed, Web of Science, Scopus, Embase, and Cochrane databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified studies reporting outcomes for patients with recurrent HGG treated via reRT ± BVZ. Cohorts were stratified by BVZ treatment status and re-irradiation modality (SRS, HFSRT, and FFRT). Outcome variables were overall survival (OS), progression-free survival (PFS), and radiation necrosis (RN). RESULTS: Data on 1399 patients was analyzed, with 954 patients receiving reRT alone and 445 patients receiving reRT + BVZ. All patients initially underwent standard-of-care therapy for their primary HGG. In a multivariate analysis that adjusted for median patient age, WHO grade, RT dosing, reRT fractionation regimen, time between primary and re-irradiation, and re-irradiation target volume, BVZ therapy was associated with significantly improved OS (2.51, 95% CI [0.11, 4.92] months, P = .041) but no significant improvement in PFS (1.40, 95% CI [- 0.36, 3.18] months, P = .099). Patients receiving BVZ also had significantly lower rates of RN (2.2% vs 6.5%, P < .001). CONCLUSIONS: Combination of reRT + BVZ may improve OS and reduce RN rates in recurrent HGG, but further controlled studies are needed to confirm these effects.

Bioengineered recombinant vault nanoparticles coupled with NY-ESO-1 glioma-associated antigens induce maturation of native dendritic cells.

PURPOSE: Glioblastoma prognosis remains grim despite maximal, multimodal management. Recent literature has demonstrated an increase in research devoted to experimental treatments, particularly those relying on the foundations of active immunotherapy with promising results. We hypothesize that the utilization of bioengineered recombinant vault nanoparticles coupled with glioma-associated antigens, such as the NY-ESO-1 peptide, may be capable of stimulating native dendritic cell (DC) maturation and inducing an anti-tumor response. METHODS: Immature DCs were cultured from the bone marrow of 4-6-week-old C57BL/6 mice. The three treatment groups consisted of: (1) DC and media, (2) DC with mCherry vault, and (3) DC with NYESO and vault. DC maturity was assessed via flow cytometric evaluation of CD11c, CD86, and MHC-II. Increase in CD86 Median Fluorescence Intensity (MFI) was analyzed in the CD11c+CD86+MHC-II+ population to determine the extent of maturation RESULTS: Our findings suggest that CP-MVP-NY-ESO-1-INT recombinant vault nanoparticles are efficiently bioengineered with exceptional integrity, are quickly internalized by immature DCs for antigen processing, and result in DC maturation. CONCLUSION: This study reports our preliminary results, which demonstrate the feasibility and progress regarding our immunotherapeutic technique utilizing NY-ESO-1 packaged vault nanoparticles to prime DCs for subsequent anti-cancer therapies.

Identification of epithelial membrane protein 2 (EMP2) as a molecular marker and correlate for angiogenesis in meningioma.

PURPOSE: Although intracranial meningiomas are the most common primary brain tumor in adults, treatment options are few and have traditionally been limited to surgical resection and radiotherapy. Additional targeted therapies and biomarkers are needed, especially as complete surgical resection is frequently not feasible in many patients. METHODS: Non-pathologic brain tissue from 3 patients undergoing routine autopsies and tumor specimens from 16 patients requiring surgical resection for meningioma were collected. EMP2 protein expression was evaluated by immunohistochemistry and western blot analysis. EMP2 mRNA expression was also investigated using surgical specimens and validated by analysis of several independent NCBI GEO databases. RESULTS: EMP2 mRNA expression levels were found to be higher in meningioma relative to non-pathologic meninges (P = 0.0013) and brain (P = 0.0011). Concordantly, strong EMP2 protein expression was demonstrated in 100% of meningioma specimens from all 16 patients, with no observable protein expression in normal brain tissue samples from 3 subjects (P < 0.001). EMP2 expression was confirmed by western blot analysis in five samples, with EMP2 protein intensity positively correlating with histologic staining score (R2 = 0.780; P = 0.047). No association was found between EMP2 mRNA or protein levels and WHO grade or markers of proliferation. However, EMP2 expression was positively associated with an angiomatous pattern on histologic evaluation (P = 0.0597), VEGF-A mRNA expression (P < 0.001), and clinical markers of tumor vascularity such as operative blood loss (P = 0.037). CONCLUSIONS: EMP2 is not found in normal brain tissue, yet has shown consistently high mRNA and protein expression in meningiomas, and may serve as a useful molecular marker for these tumors.

Radiosurgery treatment is associated with improved facial nerve preservation versus repeat resection in recurrent vestibular schwannomas.

BACKGROUND: Vestibular schwannomas (VSs) are benign neoplasms of the Schwann cells of cranial nerve VIII, and treatment of VS typically involves surgical resection. However, tumor recurrence may necessitate reintervention, and secondary treatment modalities include repeat surgical resection or adjuvant radiosurgery. The purpose of this study is to examine the scientific literature in order to determine whether surgical resection or radiosurgery for recurrent VS results in better tumor control, hearing preservation, and preservation of facial nerve function. METHODS: The PubMed, Scopus, Embase, Cochrane, and Web of Science databases were searched for studies reporting on patients undergoing either radiosurgery or repeat surgical resection after primary surgical resection for recurrent VS. Statistical analyses were performed on the compiled data, primarily outcome data involving tumor control, hearing preservation, and preservation of facial nerve function. RESULTS: We analyzed the data of 15 individual studies involving 359 total patients, and our results reveal that tumor control rates are comparable between adjuvant radiosurgery (91%, CI: 88-94%) and secondary resection (92%, CI 75-98%). However, adjuvant radiosurgery was shown to preserve good facial nerve function better (94%, CI 84-98%) compared to secondary surgical resection (56%, CI 41-69%). CONCLUSION: With comparable tumor control rates and better preservation of good facial nerve function, this study suggests that secondary radiosurgery for recurrent VS is associated with both optimal tumor control and preservation of good facial nerve function.

Middle cranial fossa approach for the repair of superior semicircular canal dehiscence is associated with greater symptom resolution compared to transmastoid approach.

BACKGROUND: Superior semicircular canal dehiscence (SSCD) is a disorder of the skull base that is gaining increasing recognition among neurosurgeons. Traditionally, the middle cranial fossa (MCF) approach has been used for the surgical repair of SSCD. However, the transmastoid (TM) approach is an alternative strategy that has demonstrated promising results. METHODS: We performed independent searches of a popular database to identify studies that described outcomes following the surgical repair of SSCD through MCF and TM approaches. The primary outcome was symptom resolution. RESULTS: Our analysis included 24 studies that described 230 patients that underwent either an MCF (n = 148, 64%) approach or a TM (n = 82, 36%) approach for primary surgical repair of SSCD. A greater percentage of patients in the MCF group experienced resolution of auditory symptoms (72% vs 59%, p = 0.012), aural fullness (83% vs 55%, p = 0.049), hearing loss (57% vs 31%, p = 0.026), and disequilibrium (75% vs 44%, p = 0.001) when compared to the TM group. The MCF approach was also associated with higher odds of symptom resolution for auditory symptoms (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.14-2.82), aural fullness (OR 4.02, 95% CI 1.04-15.53), hearing loss (OR 2.91, 95% CI 1.14-7.42), and disequilibrium (OR 3.94, 95% CI 1.78-8.73). The mean follow-up was 9 months. CONCLUSIONS: The literature suggests that the MCF approach for the repair of SSCD is associated with greater symptom resolution when compared to the TM approach. This information could help facilitate patient discussions.

Teratomas of the cranial vault: a systematic analysis of clinical outcomes stratified by histopathological subtypes.

BACKGROUND: Teratomas of the cranial vault are divided into histopathological subtypes and grouped by prognoses: mature (good prognosis), mixed/malignant and immature teratomas (intermediate prognosis). This schema also includes non-teratomatous tumors. The authors of this study sought to elucidate histologically dependent predictors of survival and further clarify the classification system of intracranial teratomas. METHODS: We performed a systematic analysis of the published literature to identify studies describing patients with intracranial teratomas diagnosed with magnetic resonance imaging (MRI) and presenting definite information on histologies, therapies, and outcomes at a minimum follow-up of 2 years. Disease-free (DFS) and overall survival (OS) were evaluated. RESULTS: A total of 18 articles comprised of 134 patients were included. On univariate analysis, male sex and gross-total resection (GTR) were associated with high mean DFS (p = 0.0362 and p < 0.0001, respectively). On multivariate analysis, mature teratomas located in the pineal, and those having undergone subtotal resection (STR) demonstrated high mean OS (p = 0.0023 and p = 0.0044, respectively). Mature and mixed/malignant suprasellar teratomas had equally higher mean OS versus immature suprasellar teratomas (p < 0.0001). Mature and immature teratomas treated with adjuvant therapy had significantly higher mean OS compared to those managed with surgery alone (p = 0.0421 and p = 0.0423, respectively). Males with immature teratomas had the highest mean OS (p < 0.0001). Immature teratomas managed with surgery alone had higher mean DFS, but lower mean OS, compared to those treated with adjuvant therapy (p = 0.0176 and p = 0.0423, respectively). CONCLUSIONS: Our data highlight the divergent nature of the different histopathological subtypes of teratomas, and suggest that survival outcomes are multifactorial. Specifically, male sex, pineal, suprasellar, GTR, and STR were dependent predictors of OS, while histopathology was an independent predictor of OS.

Gender-Based Disparities in Academic Productivity Arise During Neurosurgery Residency: A Systematic Review.

BACKGROUND: Although female neurosurgery residents are increasing, women remain underrepresented in academic leadership. OBJECTIVES: To assess academic productivity differences between male and female neurosurgery residents. METHODS: We used the Accreditation Council for Graduate Medical Education records to obtain 2021-2022 recognized neurosurgery residency programs. Gender was dichotomized into male/female by male-presenting/female-presenting status. Extracted variables included degrees/fellowships from institutional websites, number of preresidency and total publications from PubMed, and h -indices from Scopus. Extraction occurred from March to July 2022. Residency publication number and h- indices were normalized by postgraduate year. Linear regression analyses were conducted to assess factors associated with numbers of in-residency publications. P < .05 was considered statistically significant. RESULTS: Of 117 accredited programs, 99 had extractable data. Information from 1406 residents (21.6% female) was successfully collected. 19 687 and 3261 publications were evaluated for male residents and female residents, respectively. Male and female residents' median preresidency publication numbers did not significantly differ (M:3.00 [IQR 1.00-8.50] vs F:3.00 [IQR 1.00-7.00], P = .09), nor did their h -indices. However, male residents had significantly higher median residency publications than female residents (M:1.40 [IQR 0.57-3.00] vs F:1.00 [IQR 0.50-2.00], P < .001). On multivariable linear regression, male residents (odds ratio [OR] 2.05, 95% CI 1.68-2.50, P < .001) and residents with more preresidency publications (OR 1.17, 95% CI 1.16-1.18, P < .001) had higher likelihood of publishing more during residency, controlling for other covariates. CONCLUSION: Without publicly available, self-identified gender designation for each resident, we were limited to review/designate gender based on male-presenting/female-presenting status from gender conventions of names/appearance. Although not an ideal measurement, this helped show that during neurosurgical residency, male residents publish significantly more than female counterparts. Given similar preresidency h- indices and publication records, this is unlikely explained by differences in academic aptitude. In-residency gender barriers to academic productivity must be acknowledged and addressed to improve female representation within academic neurosurgery.

Customized polyetheretherketone (PEEK) implants are associated with similar hospital length of stay compared to autologous bone used in cranioplasty procedures.

OBJECTIVE: Cranioplasty is the surgical repair of cranial defects. Throughout its history, a number of different materials have been used, however, there is still no consensus on which material or method is best. The purpose of this study was to analyze the viability of polyetheretherketone (PEEK) cranioplasty to autologous cranioplasty modalities. METHODS: A single-institution retrospective analysis of patients undergoing cranioplasties was performed. Patients were divided to PEEK and autologous cranioplasty cohorts. Parameters of interest included patient demographics and perioperative outcomes. A p-value <0.05 was considered statistically significant. RESULTS: A total of 66 patients met the inclusion criteria (PEEK: 22, autologous: 44). There were 36 males (54.5%) and 30 females (45.5%). Mean age of the entire cohort was 51.7 years (range 19-85 years). Baseline demographics were similar in both cohorts as measured by the modified frailty index (mFI) (p = 0.67). Univariate analysis revealed a significantly longer hospital length of stay (LoS) associated with the autologous group (p = 0.02). However, multivariate analysis did not yield such an association (p = 0.06) after controlling for mFI. Although the individual postoperative complication rates were similar between the two cohorts, autologous cranioplasty was associated with a significantly higher rate of total postoperative complications (65.9% vs 36.4%, p = 0.02). CONCLUSION: Overall, PEEK biomaterials may offer a superior complication profile with similar hospital LoS compared to autologous bone implants used in cranioplasty. Future studies are warranted to validate our findings and further evaluate the utility of PEEK in cranioplasty.

Stereotactic Radiosurgery for Glomus Jugulare Tumors: Systematic Review and Meta-Analysis.

BACKGROUND: Glomus jugulare tumors (GJTs) are benign paragangliomas of the jugular foramen. Traditional management of these tumors involves surgical resection; however, considering the proximity of these tumors to important neurovasculature, stereotactic radiosurgery (SRS) may be an appropriate noninvasive treatment to consider. The aim of this meta-analysis was to evaluate SRS as a treatment option for GJTs. METHODS: An online search using PubMed, Web of Science, Scopus, and Cochrane databases was performed in March 2019 for articles on radiosurgery treatment of GJTs. The screening process followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: The final analysis comprised 23 studies including 460 patients. Average rates of tinnitus, hearing loss, and lower cranial nerve deficit as presenting symptoms were 56% (95% confidence interval [CI], 46%-66%), 56% (95% CI, 44%-68%), and 42% (95% CI, 31%-54%), respectively. Overall clinical status improvement rate after treatment was 47% (95% CI, 37%-57%). Rates of tinnitus, hearing loss, and lower cranial nerve improvement after treatment were 54% (95% CI, 44%-63%), 28% (95% CI, 19%-40%), and 22% (95% CI, 11%-39%), respectively. The mean follow-up time across studies was 47 months (range, 4-268 months). The aggregate tumor control rate at the time of follow-up was 95% (95% CI, 93%-97%). CONCLUSIONS: The tumor control rate of 95% and 47% symptomatic improvement suggest that SRS may be a suitable treatment modality for these hypervascular skull base tumors. Future studies are warranted to further evaluate the potential role of SRS in management of GJTs.

Hypertonic Saline Treatment in Traumatic Brain Injury: A Systematic Review.

Hypertonic saline (HTS) is a widely used adjunct in the treatment of traumatic brain injury (TBI). However, there is significant variability in practice patterns. Toward the goal of optimality and standardization in the use of HTS in TBI, we performed a comprehensive review of clinical protocols reported in the neurosurgical and neurocritical care literature. PubMed, Web of Science, Cochrane, Scopus, and Embase were independently queried between October and November 2021. The PRISMA guidelines were used throughout the screening process. We identified 15 high-quality studies representing data from 535 patients. We extracted patient demographics, Glasgow Coma Scale (GCS) score, mechanism of injury, HTS dosage, and rate of administration. Various HTS concentrations including 3%, 5%, 7.2%, 7.5%, and 20% were used. Modes of HTS administration included bolus (n = 125) and infusion (n = 376). Average length of stay was 22.4 days. Patient GCS score on initiation of HTS was depressed (average mean, 7.15; average median, 4.25 for studies reporting mean and median GCS, respectively). Excluding 2 studies with ambiguous doses, the mean HTS dosage was 2.7 × 102 mL across 8 studies and 2.5 mL/kg across 5 (with average post-HTS osmolality level of 304.6 mOsm/L reported in 3 studies). Infusions of 3% and 7.5% HTS are the most used concentrations given their efficacy in reducing intracranial pressure (ICP) and improving GCS score. In addition, lower HTS concentrations strongly correlated with greater ICP reduction. Therefore, lower concentrations of HTS may be practical therapeutic agents for patients with TBI given their efficacy in ICP reduction and safer complication profile compared with greater HTS concentrations. Evidence-based parametric use of HTS stands to improve patient outcomes by standardization of varied clinical practice.

Novel grading system of sigmoid sinus dehiscence for radiologic evaluation of pulsatile tinnitus.

BACKGROUND: Sigmoid sinus dehiscence (SSD) is an important etiology of pulsatile tinnitus (PT) though there is currently no consensus on the prevalence of SSD in non-PT populations. This study establishes a grading system of SSD and analyzes a non-PT cohort for prevalence of SSD. METHODS: In this retrospective study temporal bone CT scans of 91 patients without PT were analyzed for SSD. The dehiscence was divided into three grades: Grade 1 indicating a micro dehiscence of <3.5 mm with an opening to the mastoid air cells, Grade 2 indicating a major dehiscence of >3.5 mm with an opening to the mastoid air cells, and Grade 3 indicating a sigmoid sinus wall dehiscence opening directly to the underlying tissue. RESULTS: In patients without PT, SSD occurred in 34% of the cohort. Of these, 75% were Grade 1 and 25% were Grade 2. The range of dehiscence measurements for Grade 1 dehiscences was 0.9-3.4 mm. The range of dehiscence measurements for Grade 2 was 4-7.5 mm. There were no cases of Grade 3 dehiscence among this cohort. CONCLUSIONS: SSD occurred in over a third of our non-symptomatic cohort. While all grades of SSD may currently be treated surgically, a large portion of non-PT patients may have these sigmoid sinus anomalies asymptomatically. This grading system allows for the standardization of SSD definition and severity in future studies. Grade 3 dehiscences were completely absent in this cohort of non-PT patients.

Hearing Preservation in a Vestibular Schwannoma Patient via a Retrosigmoid Approach.

Vestibular schwannoma(s) (VS) are benign tumors of the cerebellopontine angle comprising the Schwann cells that line the vestibular branch of cranial nerve VIII. Treatment goals focus on the preservation and improvement of facial nerve and hearing function as well as tumor control. The retrosigmoid (RS) approach is associated with lower hearing preservation rates compared to the middle cranial fossa (MCF) approach. A 60-year-old male was diagnosed with right-sided cystic VS and subsequently underwent surgical resection via a RS approach. Although his preoperative hearing function was quite low, with a right-sided speech reception threshold of 35 dB and a right-sided word recognition score of 48%, he experienced a drastic improvement in his hearing postoperatively with stable residual tumor. Although the RS approach for VS resection is not considered to be as effective at preserving hearing function compared to the MCF approach, we present a case where it resulted in significantly improved hearing function. Additionally, in cases where preoperative hearing function is severely diminished, hearing preservation is not typically an outcome that is considered. However, this case suggests that improvement of hearing in these patients may be attainable, particularly with the RS approach.

Adjuvant radiotherapy for atypical meningiomas is associated with improved progression free survival.

PURPOSE: To assess the progression-free survival benefits of adjuvant radiotherapy (ART) following surgical resection compared to surgery alone in high-grade meningioma patients. METHODS: We retrospectively identified 43 patients with atypical meningiomas, who underwent either radiotherapy post-surgical resection (Surgery+ART) or surgery alone (Surgery alone) at our institution between February 2007 to March 2019. GTR was achieved in 28 patients, and STR, in 11. Patient, meningioma, and treatment data were extracted from records and compared using Kaplan-Meier methodology, log-rank tests, and Cox proportional hazard models. Radiation complications were also evaluated. RESULTS: Overall 32.6% (n = 14) of patients, 6 patients in the Surgery+ART group and 8 in the Surgery alone group, experienced recurrence. In the Surgery+ART group, the median PFS time was 46.5 months (CI: [35.8-50.6]), compared to 24.5 months (CI: [18.3-32.9]) in the Surgery alone group. 2-year PFS for Surgery+ART was 100% vs. 69.0% for Surgery alone, and the 5-year PFS rate was 70.6% and 39.2%, respectively (log-rank p-value = .004). CONCLUSIONS: Our data revealed a significant PFS increase for those treated with adjuvant radiotherapy following surgery compared to surgery alone. Future prospective studies evaluating differing radiation modalities and dosages should be conducted.

A systematic review of stereotactic radiofrequency ablation for hypothalamic hamartomas.

BACKGROUND: The seizure activity associated with hypothalamic hamartomas (HHs) is refractory to medical management and surgical intervention is often required. Stereotactic Radiofrequency Ablation (SRFA) is a minimally invasive technique offering targeted lesion ablation with a reduced risk of complications. OBJECTIVE: Here, we review the current literature on the use of SRFA for HHs. METHODS: This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic literature review. A database search of PubMed, Cochrane, Embase, and Web of Science was conducted in July 2020. RESULTS: A total of 12 articles were included in this review, showing outcomes for 185 unique patients. Of these patients, 142 (76.8%) experienced some extent of therapeutic benefit in alleviating seizures following SRFA, with 128 (69.2%) patients achieving complete freedom from seizures. Common transient complications included hyponatremia (52 patients, 28.1%), hyperphagia (48 patients, 25.9%), hyperthermia (47 patients, 25.4%), Horner's syndrome (103 patients, 55.7%), and weight gain (75 patients, 40.5%). CONCLUSIONS: SRFA is a potential therapy for patients with HHs, especially when resection confers significant risk to surrounding structures. Multiple rounds of SRFA treatment may be needed in approximately a quarter of patients to improve gelastic seizure outcomes but may not affect non-gelastic seizures. There is limited data on the use of SRFA for HHs and further case series and clinical trials are needed to establish the use of SRFA for HHs.

Analysis of temporal bone thickness outside of the petrous temporal bone between superior semicircular canal dehiscence and normal patients.

BACKGROUND: SSCD is a rare inner ear disorder. This study aims to compare the thickness of the temporal bone beyond the petrous portion between healthy subjects and those with SSCD to determine whether the etiopathology of SSCD is localized to the petrous temporal bone or generalized to other parts of the temporal bone. METHODS: A retrospective chart review of electronic medical records from September 2011 to February 2018 was conducted at a single-institution study at the University of California, Los Angeles. Participants were divided into two groups: Group 1 had a confirmed diagnosis of SSCD, while Group 2 had no known ear or temporal bone pathology. Participants' high-resolution coronal and axial temporal bone computed tomography scans were analyzed. Regions within the temporal bone were measured and compared between the two groups. RESULTS: A total of 262 scans were included. Group 1 consisted of 103 scans, while Group 2 consisted of 159 scans. There was no statistically significant difference in the thickness of temporal bones between patients diagnosed with SSCD and patients without otologic disease. CONCLUSION: The results suggest that the etiology of SSCD is limited to the petrous portion of the temporal bone. SSCD may be unrelated to a larger process of global temporal bone degeneration. Additional clinical screening for regions outside the petrous temporal bone is not warranted unless SSCD patients present with symptoms characteristic of other temporal bone pathologies.

Concurrent superior semicircular canal dehiscence and endolymphatic hydrops: A novel case series.

INTRODUCTION: Superior semicircular canal dehiscence (SSCD) is characterized by CT-confirmed bony erosion over the superior semicircular canal, creating vestibular and auditory symptoms. Endolymphatic hydrops (EH) is characterized by an MRI-confirmed excess of endolymph within the scala media that distorts the membranous labyrinth. While there is overlap in symptoms, the two diseases result from different pathophysiologies and require different interventions. PRESENTATION OF CASES: A retrospective chart review was conducted at the University of California, Los Angeles on a database of 270 adult SSCD patients, gathered between March 2011 and February 2020. A review of clinical notes, post-operative findings, and imaging was performed for 16 patients who had both CT-confirmed SSCD and an MRI of the internal auditory canal (IAC). Three cases of concurrent SSCD and EH were identified. Medical and surgical history, symptom progression pre- and post-operatively, and treatment outcomes were gathered. One patient's symptoms were resolved via mycophenolate mofetil, another's via hydrochlorothiazide, and the third's via hydrochlorothiazide and bilateral hearing aids. DISCUSSION: Post-surgical persistence of SSCD symptoms that are mutually shared with EH is the strongest indicator that a physician should investigate for concurrent EH. VEMP and audiogram testing in these cases can be misleading and should not be relied on as rule-in or rule-out tests. CONCLUSION: Concurrent SSCD and EH is a rare but treatable entity. Physicians should consider ordering an MRI of the IAC if SSCD patients' symptoms persist or recur after a successful surgery.

Selective scalp block decreases short term post-operative pain scores and opioid use after craniotomy: A case series.

There is no consensus on the management of post-craniotomy pain. Several randomized controlled trials have examined the use of a regional scalp block for post-craniotomy pain. We aim to investigate whether scalp block affected short or long-term pain levels and opioid use after craniotomy. This study prospectively administered selective scalp blocks (lesser occipital, preauricular nerve block + pin site block) in 20 consecutive patients undergoing craniotomy for semicircular canal dehiscence. Anesthesia, pain, and opioid outcomes in these patients were compared to 40 consecutive historic controls. There was no significant difference in patient demographics between the two groups and no complications related to selective scalp block. The time between the end of procedure and end of anesthesia decreased in the scalp block group (16 vs 21 min, P = 0.047). Pain scores were significantly less in the scalp block group for the first 4 h, after which there was no statistically significant difference. Time to opioid rescue was longer in the scalp block group (3.6 vs 1.8 h, HR 0.487, P = 0.0361) and opioid use in the first 7 h was significantly less in the scalp block group. Total opioid use, outpatient opioid use, and length of stay did not differ. Selective scalp block is a safe and effective tool for short-term management of postoperative pain after craniotomy and decreases the medication requirement during emergence and recovery. Selective scalp block can speed up OR turnover but is not efficacious in the treatment of postoperative pain beyond this point.