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1.
Cureus ; 16(4): e57931, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-38738035

RESUMEN

Left-handed surgical trainees are uniquely challenged when learning how to suture using standard needle drivers designed for right-handed individuals and often feel disadvantaged in comparison to their right-handed peers. "Palming," a suturing technique that improves suturing mechanics and efficiency, cannot be achieved in the standard manner using the left hand. This paper proposes a previously undescribed technique for palming using the left hand that provides many of the same benefits as standard palming methods using the right hand, potentially reducing a common source of inequity in surgical training.

2.
Acta Neurochir (Wien) ; 165(12): 4183-4189, 2023 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-37831227

RESUMEN

PURPOSE: The population is aging, and age remains an important factor in deciding surgical candidacy for intracranial tumors. The natural history and surgical behavior of meningiomas in octogenarians are not well understood. We evaluated the surgical and functional outcomes, including survival, among octogenarians with intracranial meningiomas in a single institution. METHODS: The Tumor Registry (2004-2021) was used to identify octogenarian patients (ages 80-89) diagnosed with intracranial meningioma. Primary endpoints were 1-year survival and functional outcome measured with mRS postsurgery. Kaplan-Meier, univariable Log-rank tests, and multivariable Cox hazards proportional regression models were used for assessing factors associated with overall survival (OS) in octogenarians with meningiomas who underwent surgery; logistic regression and McNemar's were used to further characterize risk factors affecting functional surgical outcome at 1 year. RESULTS: Thirty octogenarians with intracranial meningioma who underwent surgery were identified. Median age was 82.5 years and 66.6% were female patients. The 1-year median postsurgical survival probability for all octogenarians with meningioma was 86.3% and no intraoperative mortality was observed. Frailty (mFI-5, p = 0.84), tumor grade (p = 0.11), tumor size (p = 0.22), extent of resection (p = 0.35), and Karnofsky scale on admission (p = 0.93) did not significantly affect the survival in octogenarians with meningiomas which were treated surgically. The 1-year postoperative functional status of octogenarian meningioma patients who underwent surgery was significantly improved compared to pre-op mRS (McNemar's chi-squared = 9.6, df = 1, p-value = 0.001946). CONCLUSION: In octogenarians with meningiomas, surgical intervention significantly improves the pre-operative modified Rankin Scale at 1 year postsurgery in this cohort.


Asunto(s)
Neoplasias Meníngeas , Meningioma , Anciano de 80 o más Años , Humanos , Femenino , Masculino , Meningioma/patología , Octogenarios , Neoplasias Meníngeas/cirugía , Neoplasias Meníngeas/patología , Estudios Retrospectivos , Resultado del Tratamiento
3.
World Neurosurg X ; 19: 100176, 2023 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-37123627

RESUMEN

Background: Hospital length of stay (LOS) related to craniotomy for tumor resection (CTR) is a marker of neurosurgical quality of care. Limiting LOS benefits both patients and hospitals. This study examined which factors contribute to extended LOS (eLOS) at our academic center. Methods: Retrospective medical record review of 139 consecutive CTRs performed between July 2020 and July 2021. Univariate and multivariable analyses determined which factors were associated with an eLOS (≥8 days). Results: Median LOS was 6 days (IQR 3-9 days). Fifty-one subjects (36.7%) experienced an eLOS. Upon univariate analysis, potentially modifiable factors associated with eLOS included days to occupational therapy (OT), physical therapy (PT), and case management clearance (p < .001); and discharge disposition (p < .001). Multivariable analysis revealed that pre-operative anti-coagulant use (OR 10.74, 95% CI 2.64-43.63, p = .001), Medicare (OR 4.80, 95% CI 1.07-21.52, p = .04), ED admission (OR 26.21, 95% CI 5.17-132.99, p < .001), transfer to another service post-surgery (OR 30.00, 95% CI 1.56-577.35, p = .02), and time to post-operative imaging (OR 2.91, 95% CI 1.27-6.65, p = .01) were associated with eLOS. Extended LOS was not significantly associated with ED visits (p = .45) or unplanned readmissions within 30 days of surgery (p = .35), and both (p = .04; p = .04) were less likely following a short LOS (<5 days). Conclusion: While some factors driving LOS related to CTR are uncontrollable, expedient pre- and post-operative management may reduce LOS without compromising care.

4.
Brain Tumor Res Treat ; 11(2): 103-113, 2023 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37151152

RESUMEN

BACKGROUND: Cerebral chondrosarcoma metastases are rare and aggressive neoplasms. The rarity of presentation has precluded rigorous analysis of diagnosis, risk factors, treatment, and survival. We analyzed every reported case through exhaustive literature review. We further present the first case with Maffucci syndrome. METHODS: Three databases, PubMed, Embase, and Google Scholar, and crossed references were queried for cerebral chondrosarcoma metastases. Extracted variables included demographics, risk factors, tumor characteristics, interventions, and outcomes. Univariate and multivariate analyses were performed. RESULTS: Fifty-six patients were included from 1,489 literature results. The average age at brain metastasis was 46.6±17.6 years and occurred at a median of 24±2.8 months from primary diagnosis. Primary tumor histology (dedifferentiated 5.0±1.5 months, mesenchymal 24±3.0 months, conventional 41±7.4 months, p<0.05) and grade (low grade 54±16.7 months vs. high-grade 10±6.4 months, p<0.001) correlated with time interval until brain metastasis. A multiple enchondromatosis syndrome occurred in 13.2% of cases. At time of brain metastases diagnosis, extracranial metastases were identified in 76.2% of cases. Median survival after the development of brain metastasis was 2.0±0.78 months with a 1-year survival of 10.0%. On regression analysis, surgery reduced brain metastasis mortality risk and radiation trended towards reduced mortality risk (surgery: hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.064-0.763, p=0.017; radiation: HR 0.31, 95% CI 0.091-1.072, p=0.064). CONCLUSION: We present a systematic review of cerebral chondrosarcoma metastases. Primary tumor histology and grade correlate with time until cerebral metastasis. Following cerebral metastasis, these tumors have poor prognosis and modestly benefit from surgery.

5.
Brain Tumor Res Treat ; 11(2): 114-122, 2023 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37151153

RESUMEN

BACKGROUND: Surgical intervention for brain tumor patients aged 80 to 89 years is controversial, as the comorbidities and physiology associated with aging are often thought to increase surgical risks. Surgical outcomes, however, are not well characterized for octogenarians. This review therefore assessed the outcomes and mortality risk associated with tumor removal in octogenarians at our academic institution. METHODS: Retrospective review of patients aged 80 to 89 who underwent craniotomy for tumor resection (CTR) at our institution between 2004-2021 and who were diagnosed with meningioma, glioblastoma, or metastatic disease. Primary outcome was 30-day mortality. RESULTS: Sixty-one CTRs were included in analysis. Median age was 83 (interquartile range 81-85) years, and the most common preoperative comorbidity was hypertension (n=44). Most patients (n=35) had a preoperative modified Rankin Scale (mRS) score between 0-2. Seventeen (27.9%) patients experienced postoperative complications (i.e., urinary tract infection, deep venous thrombosis, etc.), and 26.2% (n=16) experienced new-onset neurologic deficits postoperatively (i.e., aphasia, motor deficits, etc.). Upon discharge, most patients (n=43) had an mRS score of 3-4. Within 30 days of surgery, 14.8% (n=9) of patients were readmitted to the hospital and 8.2% (n=5) of patients died: 2 with meningioma, 1 with glioblastoma, and 2 with metastatic disease. The most common cause of death was intracranial hemorrhage (n=3). Three-month mortality was 23.0% (n=14). Mean survival after surgery was 33 months for meningioma patients, 6.9 months for glioblastoma patients, and 15 months for patients with metastatic lesions. CONCLUSION: Our review found a 30-day mortality rate of 8.2% across all tumor types, and mean survival was similar to that previously reported for patients across all age groups. Surgical intervention for octogenarian tumor patients is therefore feasible, safe, and likely worthwhile for extending and improving lives.

6.
Brain Tumor Res Treat ; 11(2): 145-152, 2023 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37151157

RESUMEN

Music experience and creation is a complex phenomenon that involves multiple brain structures. Music mapping during awake brain surgery, in addition to standard speech and motor mapping, remains a controversial topic. Music function can be impaired selectively, despite overlap with other neural networks commonly tested during direct cortical stimulation. We describe the case of a 34-year-old male patient presenting with a glioma located within eloquent cortex, who is also a professional musician and actor. We performed an awake craniotomy (AC) that mapped the standard motor and speech areas, while the patient played guitar intraoperatively and sang. Outcomes were remarkable with preservation of function and noted improvements in his musical abilities in outpatient follow-up. In addition, we performed a review of the literature in which awake craniotomies were performed for the removal of brain tumors in patients with some background in music (e.g., score reading, humming/singing). To date, only 4 patients have played a musical instrument intraoperatively during an AC for brain tumor resection. Using awake cortical mapping techniques and paradigms for preserving speech function during an intraoperative musical performance with singing is feasible and can yield a great result for patients. The use of standard brain mapping over music processing mapping did not yield a negative outcome. More experience is needed to understand and standardize this procedure as the field of brain mapping continues to grow for tumor resections.

7.
Oper Neurosurg (Hagerstown) ; 24(6): 602-609, 2023 06 01.
Artículo en Inglés | MEDLINE | ID: mdl-37039586

RESUMEN

BACKGROUND: Compared with the Leksell G frame, the new Leksell Vantage stereotactic headframe offers many benefits during deep brain stimulation (DBS) procedures. OBJECTIVE: To define the "real-world" targeting accuracy of the Vantage frame for performing DBS lead implants. METHODS: Retrospective review of all patients who underwent DBS using the Vantage frame with our surgeon between July 2021 and May 2022. Target and actual coordinates of implanted DBS leads were determined in BrainLab. RESULTS: Thirty-three electrode trajectories (17 left-sided, 16 right-sided) were included. On the right, actual electrode placement was, on average, 0.95 mm more medial, 1.06 mm more posterior, and 0.55 mm more superior compared with planned trajectories. The vector error was 1.93 ± 0.91 mm. On the left, actual electrode placement was 0.49 mm more lateral, 0.66 mm more posterior, and 0.67 mm more superior than planned trajectories. The vector error was 1.68 ± 0.66 mm. After excluding all electrodes that were repositioned after microelectrode recording and/or test stimulation, right-sided electrodes (n = 10) were 0.88 mm more medial, 0.94 mm more posterior, and 0.76 mm more superior than planned trajectories. The vector error was 1.74 ± 1.01 mm. Left-sided electrodes (n = 14) were 0.49 mm more lateral, 0.63 mm more posterior, and 0.49 mm more superior than planned trajectories. The vector error was 1.62 ± 0.68 mm. CONCLUSION: This study demonstrated the accuracy of the Leksell Vantage frame in comparison with the traditional Leksell G frame.


Asunto(s)
Estimulación Encefálica Profunda , Técnicas Estereotáxicas , Humanos , Estimulación Encefálica Profunda/métodos , Estudios Retrospectivos , Electrodos Implantados , Imagenología Tridimensional/métodos
8.
J Neurooncol ; 162(1): 109-118, 2023 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-36809604

RESUMEN

PURPOSE: Meningioma is the most common primary central nervous system tumor often causing serious complications, and presently no medical treatment is available. The goal of this study was to discover miRNAs dysregulated in meningioma, and explore miRNA-associated pathways amenable for therapeutic interventions. METHODS: Small RNA sequencing was performed on meningioma tumor samples to study grade-dependent changes in microRNA expression. Gene expression was analyzed by chromatin marks, qRT-PCR and western blot. miRNA modulation, anti-IGF-2 neutralizing antibodies, and inhibitors against IGF1R were evaluated in a tumor-derived primary cultures of meningioma cells. RESULTS: Meningioma tumor samples showed high, grade-dependent expression of miR-483-5p, associated with high mRNA and protein expression of its host gene IGF-2. Inhibition of miR-483-5p reduced the growth of cultured meningioma cells, whereas a miR-483 mimic increased cell proliferation. Similarly, inhibition of this pathway with anti-IGF-2 neutralizing antibodies reduced meningioma cell proliferation. Small molecule tyrosine kinase inhibitor blockade of the IGF-2 receptor (IGF1R) resulted in rapid loss of viability of cultured meningioma tumor-derived cells, suggesting that autocrine IGF-2 feedback is obligatory for meningioma tumor cell survival and growth. The observed IGF1R-inhibitory IC50 for GSK1838705A and ceritinib in cell-based assays along with the available pharmacokinetics data predicted that effective drug concentration could be achieved in vivo as a new medical treatment of meningioma. CONCLUSION: Meningioma cell growth is critically dependent on autocrine miR-483/IGF-2 stimulation and the IGF-2 pathway provides a feasible meningioma treatment target.


Asunto(s)
Neoplasias Meníngeas , Meningioma , MicroARNs , Humanos , Supervivencia Celular , Meningioma/genética , Receptor IGF Tipo 1/genética , MicroARNs/genética , MicroARNs/metabolismo , Proliferación Celular/genética , Línea Celular Tumoral , Neoplasias Meníngeas/genética , Regulación Neoplásica de la Expresión Génica
9.
Oper Neurosurg (Hagerstown) ; 24(3): 276-282, 2023 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-36701570

RESUMEN

BACKGROUND: Deep brain stimulation (DBS) is the mainstay of surgical treatment for movement disorders, yet previous studies have shown widely varying complication rates. Given the elective nature of DBS surgery, minimizing surgical complications is imperative. OBJECTIVE: To evaluate short-term and long-term complications related to DBS lead implantation surgeries performed by an experienced surgeon and provide an updated benchmark comparison for other DBS centers and alternative therapies. METHODS: A retrospective chart review of patients who underwent DBS lead implantation surgery by a single surgeon at our institution between 2012 and 2020 was conducted. Demographic and clinical data including surgical complications were collected. A Kaplan-Meier survival analysis was used to evaluate the cumulative risk of lead revision or removal over time. Associations between patient characteristics and various complications were evaluated. RESULTS: Four hundred fifty-one DBS leads were placed in 255 patients. Thirteen leads and 11 patients required revision. In total, 3.6% (95% CI [1.3%-5.9%]) of patients required revision at 1 year and 4.8% (95% CI [1.9%-7.6%]) at 5 years, with per-lead revision rates of 2.3% (95% CI [0.9%-3.6%]) and 3.3% (95% CI [1.5%-5.1%]), respectively. Less common diagnoses such as Tourette syndrome, post-traumatic tremor, and cluster headache trended toward association with lead revision or removal. CONCLUSION: DBS performed by an experienced surgeon is associated with extremely low complication rates.


Asunto(s)
Estimulación Encefálica Profunda , Trastornos del Movimiento , Cirujanos , Humanos , Estimulación Encefálica Profunda/efectos adversos , Estudios Retrospectivos , Temblor
10.
Brain Tumor Res Treat ; 10(3): 200-205, 2022 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-35929119

RESUMEN

Appendiceal cancer is an extremely rare malignancy, and its metastatic spread to the brain is even more unusual. We describe a 47-year-old female who presented with a rare cerebral appendiceal carcinoma metastasis, a case that is further remarkable for representing the first histologic diagnosis of primary medullary carcinoma in the appendix. Based on a comprehensive review of the English literature using PubMed, Embase, and Google Scholar, only six other cases of cerebral appendiceal metastases have been described.

11.
Neurosurgery ; 91(1): 59-65, 2022 07 01.
Artículo en Inglés | MEDLINE | ID: mdl-35319531

RESUMEN

BACKGROUND: "Moral distress" describes the psychological strain a provider faces when unable to uphold professional values because of external constraints. Recurrent or intense moral distress risks moral injury, burnout, and physician attrition but has not been systematically studied among neurosurgeons. OBJECTIVE: To develop a unique instrument to test moral distress among neurosurgeons, evaluate the frequency and intensity of scenarios that may elicit moral distress and injury, and determine their impact on neurosurgical burnout and turnover. METHODS: An online survey investigating moral distress, burnout, and practice patterns was emailed to attending neurosurgeon members of the Congress of Neurological Surgeons. Moral distress was evaluated through a novel survey designed for neurosurgical practice. RESULTS: A total of 173 neurosurgeons completed the survey. Half of neurosurgeons (47.7%) reported significant moral distress within the past year. The most common cause was managing critical patients lacking a clear treatment plan; the most intense distress was pressure from patient families to perform futile surgery. Multivariable analysis identified burnout and performing ≥2 futile surgeries per year as predictors of distress (P < .001). Moral distress led 9.8% of neurosurgeons to leave a position and 26.6% to contemplate leaving. The novel moral distress survey demonstrated excellent internal consistency (Cronbach alpha = 0.89). CONCLUSION: We developed a reliable survey assessing neurosurgical moral distress. Nearly, half of neurosurgeons suffered moral distress within the past year, most intensely from external pressure to perform futile surgery. Moral distress correlated with burnout risk caused 10% of neurosurgeons to leave a position and a quarter to consider leaving.


Asunto(s)
Agotamiento Profesional , Trastornos por Estrés Postraumático , Agotamiento Profesional/epidemiología , Agotamiento Profesional/psicología , Humanos , Principios Morales , Neurocirujanos , Encuestas y Cuestionarios
12.
World Neurosurg ; 156: 76-91, 2021 12.
Artículo en Inglés | MEDLINE | ID: mdl-34563719

RESUMEN

OBJECTIVE: Primary intracranial malignant peripheral nerve sheath tumors (MPNSTs) not associated with cranial nerves are rare and aggressive neoplasms. The rarity of presentation has precluded rigorous analysis of diagnosis, risk factors, treatment, and survival. We analyzed every reported case through exhaustive literature review. In addition, we present our own experience managed with resection, radiotherapy, and first use of targeted therapy in a tumor of this type for a BRAF mutation identified during next-generation sequencing. METHODS: Two databases, PubMed and Embase, and crossed references were queried for intracranial MPNSTs not associated with a cranial nerve. Extracted variables included demographics, risk factors, tumor characteristics, interventions, and outcomes. Univariate and multivariate analysis was performed to identify factors with survival benefit. RESULTS: A total of 56 patients (including the present case) were included from 743 literature results. There was a male/female ratio of 1.5:1 and mean diagnosis age of 29.7 ± 21.8 years. Seventy-one percent of cases were sporadic and 23% neurofibromatosis type 1 related. Median survival was 29 ± 22.1 months with 1-year survival of 60%. Factors associated on univariate analysis with reduced survival were subtotal resection (P = 0.05), older age (P = 0.023), triton histology (P < 0.001), and early recurrence (≤6 months) (P = 0.018). On multivariate analysis, gross total resection reduced mortality risk (P = 0.011), whereas triton histology (P = 0.017) and infratentorial tumor location (P = 0.037) increased mortality. CONCLUSIONS: We present a systematic review of intracranial MPNSTs not associated with a cranial nerve. These tumors have poor prognosis and benefit from aggressive resection, multimodal treatment, and close follow-up. Next-generation sequencing can show molecular alterations for potential targeted therapy.


Asunto(s)
Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/cirugía , Nervios Craneales/diagnóstico por imagen , Neoplasias de la Vaina del Nervio/diagnóstico por imagen , Neoplasias de la Vaina del Nervio/cirugía , Neoplasias de los Nervios Craneales/diagnóstico por imagen , Neoplasias de los Nervios Craneales/cirugía , Humanos , Masculino , Adulto Joven
13.
Clin Neurol Neurosurg ; 207: 106761, 2021 08.
Artículo en Inglés | MEDLINE | ID: mdl-34217006

RESUMEN

BACKGROUND: Sutures are conventionally used for external ventricular drain (EVD) catheter fixation, but staples are an appealing alternative as they are quicker and easier to learn. We report our institutional experience with EVD fixation techniques and the patterns of catheter fixation. METHODS: We conducted a retrospective review of all aneurysmal subarachnoid hemorrhage (aSAH) patients treated in a single US center between 2007 and 2017. RESULTS: Out of 307 patients, 217 patients (62.2% female, mean age 59.5 years) met inclusion criteria harboring 268 EVDs. Two main configurations were used for EVD catheter fixation; spiral-shaped EVDs in 139 (51.9%) cases and arciform (C-shaped) EVDs in 129 (48.1%) of the cases. 220 (82.1%) were secured with staples and 48 (17.9%) with sutures. The most common complication was obstruction (n = 43, 16.2%), followed by infections (n = 18, 6.8%). Catheter dislodgements occurred in 16 (5.9%) catheters and 61 (22.8%) required repositioning/replacement. EVD dislodgement rates did not differ between the staples and sutures group, or between the spiral and C-shaped EVDs (p = 0.5 and 0.93, respectively). No cases of catheter perforation by the staples were encountered in our cohort. CONCLUSION: Staples and sutures are equally valid and acceptable methods for EVD fixation with similar dislodgement rates. Scarce data exist in the literature regarding dislodgements, and further studies are needed to address its incidence and the best preventive strategies.


Asunto(s)
Catéteres , Drenaje , Hemorragia Subaracnoidea/cirugía , Grapado Quirúrgico , Suturas , Ventriculostomía , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
14.
Neurosurgery ; 88(5): 942-954, 2021 04 15.
Artículo en Inglés | MEDLINE | ID: mdl-33471896

RESUMEN

BACKGROUND: Burnout is a negative workplace syndrome of emotional exhaustion, cynicism, and perceived professional inefficacy that risks the patient-provider relationship, patient care, and physician well-being. OBJECTIVE: To assimilate the neurosurgical burnout literature in order to classify burnout among domestic and international neurosurgeons and trainees, identify contributory factors, and appraise the impact of wellness programs. METHODS: A scoping review identified the available literature, which was reviewed for key factors related to burnout among neurosurgeons. Two researchers queried PubMed, Embase, Google Scholar, Cochrane, and Web of Science for articles on burnout in neurosurgery and reduced 1610 results to 32 articles. RESULTS: A total of 32 studies examined burnout in neurosurgery. A total of 26 studies examined prevalence and 8 studies detailed impact of wellness programs. All were published after 2011. Burnout prevalence was measured mostly through the Maslach Burnout Inventory (n = 21). In 4 studies, participants defined their own understanding of "burnout." Domestically, burnout prevalence was 11.2% to 67% among residents and 15% to 57% among attendings. Among trainees, poor operative experience, poor faculty relationships, and social stressors were burnout risks but not age, sex, or marital status. Among attendings, the literature identified financial or legal concerns, lack of intellectual stimulation, and poor work-life balance as risks. The impact of wellness programs on trainees is unclear but group exercises may offer the most benefit. CONCLUSION: Noticeable methodological differences in studies on trainee and attending burnout contribute to a wide range of neurosurgery burnout estimates and yield significant knowledge gaps. Environment may have greater impact on trainee burnout than demographics. Wellness programs should emphasize solidarity.


Asunto(s)
Agotamiento Profesional , Neurocirujanos , Neurocirugia/organización & administración , Agotamiento Profesional/epidemiología , Agotamiento Profesional/prevención & control , Agotamiento Profesional/terapia , Humanos , Prevalencia
15.
Oper Neurosurg (Hagerstown) ; 19(6): 708-714, 2020 11 16.
Artículo en Inglés | MEDLINE | ID: mdl-32710790

RESUMEN

BACKGROUND: In deep brain stimulation (DBS), tunneled lead and extension wires connect the implantable pulse generator to the subcortical electrode, but circuit discontinuity and wire revision compromise a significant portion of treatments. OBJECTIVE: To identify factors predisposing to fracture or tethering of the lead or extension wire in patients undergoing DBS. METHOD: Retrospective review of wire-related complications was performed in a consecutive series of patients treated with DBS at a tertiary academic medical center over 15 yr. RESULTS: A total of 275 patients had 513 extension wires implanted or revised. There were 258 extensions of 40 cm implanted with a postauricular connector (50.3%), 229 extensions of 60 cm with a parietal connector (44.6%), and 26 extensions 40 cm with a parietal connector (5.1%). In total, 26 lead or extension wires (5.1%) were replaced for fracture. Fracture rates for 60 cm extensions with a parietal connector, 40 cm wires with a postauricular connector, and 40 cm extensions with a parietal connector were 0.2, 1.4, and 12.9 fractures per 100 wire-years, significantly different on log-rank test. Total 16 (89%) 40 cm extension wires with a postauricular connector had fracture implicating the lead wire. Tethering occurred only in patients with 60 cm extensions with parietal connectors (1.14 tetherings per 100 wire-years). Reoperation rate correlated with younger age, dystonia, and target in the GPI. CONCLUSION: The 40 cm extensions with parietal connectors have the highest fracture risk and should be avoided. Postauricular connectors risk lead wire fracture and should be employed cautiously. The 60 cm parietal wires may reduce fracture risk but increase tethering risk.


Asunto(s)
Estimulación Encefálica Profunda , Hilos Ortopédicos , Electrodos Implantados , Humanos , Estudios Retrospectivos , Factores de Riesgo
16.
World Neurosurg ; 140: 26-31, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32437992

RESUMEN

BACKGROUND: Intramedullary metastases to the caudal neuraxis with exophytic extension to the extramedullary space are rare. We describe the unique case of a patient with locally recurrent breast cancer who developed an intramedullary-extramedullary metastasis to the conus medullaris and cauda equina 22 years after primary diagnosis, the longest interval between primary breast cancer and intramedullary spread to date. We also reviewed the published literature on focal breast metastases to the conus medullaris or cauda equina. CASE DESCRIPTION: A 66-year-old woman with a history of node-positive estrogen receptor/progesterone receptor-positive, infiltrating ductal carcinoma diagnosed in 1997 and locally recurrent in 2007. Initial treatment included lumpectomy and targeted chemoradiation with mastectomy and hormonal therapy at recurrence. Twelve years later, she developed 6 weeks of bilateral buttock and leg pain without motor or sphincter compromise. Magnetic resonance imaging of the total spine revealed a 2 x 1.7 cm bilobed intradural, intramedullary-extramedullary, homogenously enhancing, T1-and T2-isointense lesion involving the conus medullaris and cauda equina. She underwent subtotal resection of a hormone receptor-positive breast metastasis. Her pain improved postoperatively and she was stable at 5 months. CONCLUSIONS: We provide evidence that patients who present with symptoms of spinal neurologic disease and a history of hormone receptor-positive breast cancer require high suspicion for metastatic pathology, despite significant time lapse from primary diagnosis. The tumor may involve both the intramedullary and extramedullary space, complicating resection. Symptom relief and quality of life should guide resection of metastatic lesions to the caudal neuraxis.


Asunto(s)
Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/secundario , Neoplasias del Sistema Nervioso Periférico/secundario , Neoplasias de la Médula Espinal/secundario , Anciano , Cauda Equina/patología , Femenino , Humanos , Factores de Tiempo
17.
World Neurosurg ; 129: 232-236, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31203061

RESUMEN

BACKGROUND: Pure fusiform aneurysms of the anterior communicating artery (AcomA) are rare. We report a unique case of a patient with an AComA fusiform aneurysm in the setting of several unusual cranial neurocristopathies, including a hypoplastic internal carotid artery (ICA), persistent craniopharyngeal canal, transsphenoidal encephalocele, and ectopic, duplicated pituitary gland. We also review the literature on cranial base neurocristopathies and AComA fusiform aneurysms. CASE DESCRIPTION: This 46-year-old patient had a history of short stature, osteoporosis, obesity, cleft lip, decreased libido, congenital left eye blindness, headaches, and chronic nasal congestion. Magnetic resonance imaging revealed a 25 × 25 × 33 mm heterogenous soft tissue mass with an ectopic pituitary gland extending transsphenoidally and a duplicated pituitary stalk. A hormone panel revealed undetectable insulin-like growth factor 1 and growth hormone, central hypogonadism, and elevated prolactin. Before presentation, computed tomography angiography (CTA) had revealed a congenitally hypoplastic right ICA and 4.7 × 10.7 mm fusiform aneurysm of the AComA. Digital subtraction angiography confirmed stable morphology after 9 years. Nonoperative management of aneurysm and cephalocele was elected, with repeat CTA in 1 year. CONCLUSIONS: This case provides evidence that inherent arterial wall defects can contribute to fusiform aneurysm formation in the AComA. We propose that small AComA fusiform aneurysms without sclerotic or symptomatic features can be safely observed by describing the longest reported conservative management for this type of aneurysm. A high degree of suspicion for cerebrovascular anomalies should be maintained in patients who present with cranial neurocristopathy.


Asunto(s)
Anomalías Múltiples , Aneurisma Intracraneal/congénito , Cresta Neural , Humanos , Aneurisma Intracraneal/patología , Masculino , Persona de Mediana Edad
18.
Childs Nerv Syst ; 34(11): 2155-2171, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-30078055

RESUMEN

PURPOSE: To provide the reader with a comprehensive but concise understanding of congenital scoliosis METHODS: We have undertaken to summarize available literature on the pathophysiology, epidemiology, and management of congenital scoliosis. RESULTS: Congenital scoliosis represents 10% of pediatric spine deformity and is a developmental error in segmentation, formation, or a combination of both leading to curvature of the spine. Treatment options are complicated by balancing growth potential with curve severity. Often associated abnormalities of cardiac, genitourinary, or intraspinal systems are concurrent and should be evaluated as part of the diagnostic work-up. Management balances the risk of progression, growth potential, lung development/function, and associated risks. Surgical treatment options involve growth-permitting systems or fusions. CONCLUSION: Congenital scoliosis is a complex spinal problem associated with many other anomalous findings. Treatment options are diverse but enable optimization of management and care of these children.


Asunto(s)
Escoliosis/congénito , Escoliosis/diagnóstico , Escoliosis/terapia , Femenino , Humanos , Masculino
19.
J Neurosurg Pediatr ; 22(4): 375-383, 2018 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-29957140

RESUMEN

The authors looked at all of the pediatric patients with a head injury who were transferred from other hospitals to their own over 12 years and tried to identify factors that would allow patients to stay closer to home at their local hospitals and not be transferred. Many patients with isolated, nondisplaced skull fractures or negative CT imaging likely could have avoided transfer. While hospitals should be cautious, this may help families stay closer to home.


Asunto(s)
Traumatismos Craneocerebrales , Transferencia de Pacientes , Centros Traumatológicos , Triaje , Adolescente , Niño , Femenino , Humanos , Masculino , Estudios Retrospectivos
20.
Neurosurg Focus ; 43(4): E2, 2017 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-28965447

RESUMEN

Adolescent idiopathic scoliosis (AIS) is a 3D spinal deformity affecting children between the ages of 11 and 18, without an identifiable etiology. The authors here reviewed the available literature to provide spine surgeons with a summary and update on current management options. Smaller thoracic and thoracolumbar curves can be managed conservatively with observation or bracing, but corrective surgery may be indicated for rapidly growing or larger curves. The authors summarize the atypical features to look for in patients who may warrant further investigation with MRI during diagnosis and review the fundamental principles of the surgical management of AIS. Patients with AIS can be managed very well with a combination of conservative and surgical options. Outcomes for these children are excellent with sustained longer-term results.


Asunto(s)
Manejo de la Enfermedad , Escoliosis/cirugía , Fusión Vertebral/métodos , Resultado del Tratamiento , Adolescente , Niño , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Escoliosis/diagnóstico por imagen
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