Gliomas: survival differences between metropolitan and non-metropolitan counties.

BACKGROUND: For gliomas, metropolitan status has not been heavily explored in the context of short-term mortality or long-term observed survival. Larger populations are associated with proximity to academic universities/high-volume hospitals. METHODS: The SEER-18 registry was queried for patients with gliomas. The patients were further classified into two population groups based on rural-urban continuum codes: metropolitan or non-metropolitan. Demographics and clinical factors were compared between both groups. For observed survival, univariate and multivariate analyses occurred with Cox proportional hazards model. RESULTS: The non-metropolitan group constituted approximately 10.8% of all patients. Age at diagnosis of glioma was older for the non-metropolitan group compared to metropolitan group (51.60 years vs. 49.06 years). Relative to the metropolitan group, the non-metropolitan group exhibited a larger proportion of Caucasian, married, grade I and IV gliomas, no surgery, no GTR (for those who had surgery), and temporal/parietal/occipital locations. Other covariates (sex, tumor size, laterality, and radiation status) did not exhibit significant differences in proportions. From analysis of observed survival, independent predictors include population group, as well as age, gender, marital status, tumor location, tumor grade, laterality, GTR, and receipt of radiation. Short-term mortality was 11.68% and 13.04% for Metropolitan and non-metropolitan groups, respectively. Median survival was 15 months and 12 months for Metropolitan and non-metropolitan groups, respectively. CONCLUSIONS: About one-tenth of gliomas are treated at non-metropolitan sites. Key differences exist among patient/glioma characteristics based on metropolitan status. Overall, metropolitan status appears to influence short-term mortality and long-term observed survival for gliomas.

Causes of death in glioblastoma: insights from the SEER database.

BACKGROUND: Glioblastoma (GB) and its variants portend a poor prognosis. The predominant cause of death (COD) is related to the cancer diagnosis, but a significant subset is related to other causes. As GB is a systemic disease requiring systemic treatment, focus regarding all COD provides a comprehensive illustration of the disease. METHODS: The SEER-18 was queried for patients with cranial GB and its variants. Age, gender, race, marital status, tumor characteristics, treatment details, and follow-up data were acquired. The patients were classified into group A (death attributed to this cancer diagnosis) or group B (death attributed to causes other than this cancer diagnosis). RESULTS: From 1973 to 2013, 36,632 deaths (94%) constituted group A, and 2,324 deaths (5.9%) constituted group B. The latter significantly exhibited lower proportions of age <60, Caucasians, married status, frontal/brain stem/ventricle tumor locations, and receipt of radiation. From logistic regression, age >60, male gender, race, not married, tumor location, and no radiation were significant independent predictors for group B. The top known CODs in group B are diseases of heart, pneumonia and influenza, cerebrovascular diseases, accidents and adverse effects, and infections. CONCLUSIONS: CODs not attributed to GB remains a significant subset of all CODs. Many of these, particularly diseases of heart, are frequent comorbidities. Moreover, infection-related CODs after GB diagnosis appear more salient compared to CODs in the general population. Consideration of these CODs, and vigilant treatment aimed at these CODs, may improve overall care for GB patients.

Modern operative nuances for the management of eloquent high-grade gliomas.

INTRODUCTION: Despite advancements in the treatment of high-grade gliomas (HGG), the rate of tumor recurrence is high and survival rate for the patient is low. Gross total resection has shown increased survival but the location of the tumor in the eloquent brain poses significant risk of morbidity. In this report, we focus on modern surgical nuances for resection of tumors located in the eloquent brain. EVIDENCE ACQUISITION: Research of the literature was conducted using the following search terms: surgical resection of gliomas, high-grade gliomas, and the role of vascular encasement - from 1986-2018. An institutional experience from the first author of this paper was also reviewed for selection of our illustrative cases. EVIDENCE SYNTHESIS: Gross total resection remains the mainstay of therapy for high-grade gliomas. The resection of the peritumoral FLAIR, when possible, has been associated with increased survival but also has the potential to cause increased morbidity. In the eloquent brain, the resection of the tumor itself is possible if attention is given to the interface of the tumor and brain, or if a safe pseudo-interface is created by the surgeon. Tumor-seeding to the ventricular system needs to be avoided. Devascularization, dissection away from the brain, and retractorless brain surgery are key to successful surgical outcomes. Management of the venous and arterial invasion/encasement are also outlined in this report. Technical aspects are discussed with corresponding videos. CONCLUSIONS: High-grade gliomas involving eloquent brain areas require a tailored treatment plan. While the medical treatment is undergoing quick evolution, gross total resection still remains one of the key milestones of treatment for improved survival. Surgical techniques play key role. We propose that encasement and/or the invasion of arteries and veins, should be considered equally as important as the eloquent brain when contemplating the resection of gliomas.

Subarachnoid Trabeculae: A Comprehensive Review of Their Embryology, Histology, Morphology, and Surgical Significance.

INTRODUCTION: Brain is suspended in cerebrospinal fluid (CSF)-filled subarachnoid space by subarachnoid trabeculae (SAT), which are collagen-reinforced columns stretching between the arachnoid and pia maters. Much neuroanatomic research has been focused on the subarachnoid cisterns and arachnoid matter but reported data on the SAT are limited. This study provides a comprehensive review of subarachnoid trabeculae, including their embryology, histology, morphologic variations, and surgical significance. METHODS: A literature search was conducted with no date restrictions in PubMed, Medline, EMBASE, Wiley Online Library, Cochrane, and Research Gate. Terms for the search included but were not limited to subarachnoid trabeculae, subarachnoid trabecular membrane, arachnoid mater, subarachnoid trabeculae embryology, subarachnoid trabeculae histology, and morphology. Articles with a high likelihood of bias, any study published in nonpopular journals (not indexed in PubMed or MEDLINE), and studies with conflicting data were excluded. RESULTS: A total of 1113 articles were retrieved. Of these, 110 articles including 19 book chapters, 58 original articles, 31 review articles, and 2 case reports met our inclusion criteria. CONCLUSIONS: SAT provide mechanical support to neurovascular structures through cell-to-cell interconnections and specific junctions between the pia and arachnoid maters. They vary widely in appearance and configuration among different parts of the brain. The complex network of SAT is inhomogeneous and mainly located in the vicinity of blood vessels. Microsurgical procedures should be performed with great care, and sharp rather than blunt trabecular dissection is recommended because of the close relationship to neurovascular structures. The significance of SAT for cerebrospinal fluid flow and hydrocephalus is to be determined.

Rare Concurrent Retroclival and Pan-Spinal Subdural Empyema: Review of Literature with an Uncommon Illustrative Case.

BACKGROUND: Subdural empyema can present as a spinal subdural empyema (SSE) or a cranial subdural empyema (CSE). Although they differ somewhat in epidemiology, etiology, pathophysiology, and symptomatology and occur separately, they rarely manifest together. The aim of this article is to review the literature concerning the clinical presentation, clinical course, and treatment options for managing concurrently occurring SSE and CSE. METHODS: The literature in the Medline database was reviewed with key words including but not limited to subdural empyema, retroclival empyema, and Streptococcus mitis. No similar reports were found in the database involving infection with this type of microorganism in this anatomical region. RESULTS: Only 3 cases with concurrent CSE and SSE were found in the literature caused by various etiologic agents. Two of the patients recovered with no neurologic deficit, whereas one fatality was reported. One new illustrative case caused by Streptococcus mitis is also presented. CONCLUSIONS: CSE and SSE are neurosurgical emergencies, often requiring prompt surgical evacuation. Although very rare, Streptococcus mitis can cause spinal subdural empyema or retroclival abscesses. Natural history of this disease is grave without treatment. Delays in diagnosis and treatment are directly related to mortality and severe morbidity in patients with intracranial and spinal subdural empyema. Prompt recognition and treatment are essential to preclude severe neurologic disabilities or in rare cases a fatal outcome. A treatment paradigm for cranio-spinal empyema is proposed.