Long-term oncological outcomes for endoscopic endonasal versus open surgical approaches for anatomically matched, locally advanced stage T4 sinonasal malignancies with skull base involvement.

OBJECTIVE: Expanded endoscopic approaches (EEAs) are increasingly used for the definitive management of sinonasal malignancies. EEAs, in appropriately selected cases, provide similar oncological outcomes but are associated with lower complication rates compared with open surgical approaches. Selection bias is a limitation reported in previous studies comparing EEAs and open surgical approaches for the management of sinonasal malignancies. To address this issue, in this study the authors compared the long-term oncological outcomes of an anatomically matched cohort of patients with locally advanced sinonasal malignancies with skull base involvement (T4 stage). The specific objective of this study was to investigate the extent of resection (EOR), overall survival (OS), and disease progression between the EEA and open surgical cohorts. METHODS: A cohort of 42 patients with locally advanced sinonasal malignancies and skull base involvement (stage T4) and operated on via an EEA was matched anatomically with a cohort of 54 patients who had undergone open surgery. A retrospective chart review was conducted on these 96 patients who were treated between September 1993 and June 2020. All patients in the cohort were eligible for either an EEA or open surgery according to anatomical criteria. Patients of all ages were included, and the minimum follow-up required for eligibility was 4 months. Patients were excluded if surgery was not offered for curative intent and preoperative imaging did not demonstrate that gross-total resection was achievable. RESULTS: There were more complications in the conventional surgery cohort than in the EEA cohort (33.33% vs 14.29%, p = 0.033). There was no significant difference in the EOR between the EEA and conventional surgery cohorts, as demonstrated by comparable rates of positive margins in both groups (5.56% vs 2.38%, respectively). Disease progression (hazard ratio [HR] 0.47, 95% CI 0.17-1.27, p = 0.137) was lower and OS (HR 0.58, 95% CI 0.26-1.29, p = 0.183) was higher in the EEA cohort, but these findings did not reach statistical significance. CONCLUSIONS: The EEA was found to be associated with lower risks of complications than conventional craniofacial surgical approaches. There were no significant differences in OS and progression-free survival between the EEA and conventional surgical cohorts when comparing anatomically matched cohorts of patients with stage T4 sinonasal malignancies and skull base involvement.

Impact of salvage surgery with or without reirradiation for skull base meningiomas recurring after prior radiotherapy.

OBJECTIVE: Long-term follow-up of meningiomas has demonstrated recurrence rates ranging from 2.5% to 48% after 10 years, depending on histology grade. There are limited data available to guide the management of recurrent and previously irradiated skull base meningiomas, and challenges related to salvage surgery, reirradiation, and lack of clear systemic therapy strategies remain. In this study, the authors analyzed data from their experience with recurrent and previously irradiated meningiomas to assess the impact of salvage surgery and reirradiation on progression-free survival (PFS). METHODS: A retrospective cohort study of 48 patients with recurrent and previously irradiated meningiomas who were treated between 1995 and 2021 was conducted. Data were extracted from medical records and included clinical, radiological, and pathologic reports. Patients were clustered according to WHO grades. The authors analyzed the complications related to reirradiation and salvage surgery and the impact of different treatment modalities on PFS using Cox proportional hazard ratios. RESULTS: Forty-eight patients (33 with WHO grade I, 11 with WHO grade II, and 4 with WHO grade III meningiomas) were treated for 143 recurrences after their first radiation treatment. For WHO grade I meningiomas, there was no change in tumor control rates with adjuvant repeat radiotherapy (HR 0.784, 95% CI 0.349-1.759; p = 0.55), and in terms of extent of resection (EOR), subtotal resection (STR) alone was associated with an increased risk of recurrence when compared with gross-total resection (GTR) (HR 3.38, 95% CI 1.268-9.036; p = 0.0189). For WHO grade II meningiomas, GTR did not significantly confer improved tumor control relative to STR (HR 0.42, 95% CI 0.17-1.037; p = 0.055), but adjuvant repeat radiotherapy after STR was associated with improved outcomes (HR 0.316, 95% CI 0.13-0.768; p = 0.0029). Finally, for WHO grade III meningiomas, EOR did not correlate with outcomes (HR 0.75, 95% CI 0.22-2.482; p = 0.588), but repeat radiotherapy alone was associated with a decreased odds of progression (HR 0.276, 95% CI 0.078-0.97; p = 0.0028). CONCLUSIONS: This study examined the impact of retreatment on PFS in a large cohort of patients with recurrent meningiomas that had been previously irradiated. At the time of recurrence, WHO grade I meningiomas exhibited improved PFS with GTR, subtotally resected WHO grade II meningiomas appeared to have improved PFS when reirradiated, and reirradiation in WHO grade III meningiomas showed improved PFS.

The impact of expanded endoscopic approaches on oncologic and functional outcomes for clival malignancies:a case series.

INTRODUCTION: Clival malignancies pose particular surgical challenges due to complex skull base anatomy and the involvement of vital neurovascular structures. While endoscopic endonasal approached are widely used, the outcomes for clival malignancies remain poorly understood. In this study we assessed the impact of endoscopic and open surgical approaches on PFS, time to initiation of radiotherapy, KPS, and GTR rates for clival malignancies. METHODS: A retrospective case series for clival malignancies operated between 1993 and 2019 was conducted. Inclusion criteria were age over 18 and a follow-up of at least a 6 months. Statistical analyses were conducted using STATA version 15 statistical software package StataCorp. RESULTS: For the whole cohort (113 patients), and for upper and middle lesions, open surgical approaches increased odds of disease progression, compared to EEA (HR 2.10 to HR 2.43), p < 0.05. EEA had a shorter time interval from surgery to initiation of radiotherapy. No difference in 6 and 12 month KPS was found between surgical groups. Patients undergoing open surgery were less likely to achieve GTR for upper clival lesions. CONCLUSIONS: EEA was found to be associated with increased PFS, for upper and middle clival malignancies. The time to initiation of radiotherapy was shorter for patients undergoing EEA compared to open surgery for patients with middle clival involvement. GTR rates were found to be significantly better with EEA for patients with upper clival malignancies.

Impact of salvage surgery for recurrent sinonasal cancers with skull base and intracranial involvement.

OBJECTIVE: Patients with recurrent sinonasal cancers (RSNCs) often present with extensive involvement of the skull base and exhibit high rates of subsequent recurrence and death after therapy. The impact of salvage surgery and margin status on progression-free survival (PFS) and overall survival (OS) has yet to be demonstrated. The goal of this study was to determine whether skull base resection with negative margins has an impact on outcomes in the recurrent setting. METHODS: A retrospective chart review of 47 patients who underwent surgery for RSNC with skull base invasion between November 1993 and June 2020 was conducted. The following variables were extracted from the clinical records: patient demographic characteristics (age and sex), tumor pathology, dural and orbital invasion, and prior radiation exposure and induction chemotherapy. Metastatic disease status, surgical approach, margin status, and history of postoperative chemotherapy and/or postoperative radiation therapy were noted. The primary and secondary outcomes were PFS and OS, respectively. RESULTS: The cohort included 30 males (63.8%) and 17 females (36.2%), with a mean ± SD age of 54.8 ± 14.4 years. Thirty-five (74.5%) patients showed disease progression, and 29 (61.7%) patients died during the study period. The mean ± SD patient follow-up period was 61.8 ± 64.4 months. Dural invasion was associated with increased risk of death (HR 2.62, 95% CI 1.13-6.08). High-risk histopathology (HR 3.14, 95% CI 1.10-8.95) and induction chemotherapy (HR 2.32, 95% CI 1.07-5.06) were associated with increased odds of disease progression. When compared to patients with positive margins or gross-total resection with unknown margin status, those with negative margins had decreased odds of disease progression (HR 0.30, 95% CI 0.14-0.63) and death (HR 0.38, 95% CI 0.17-0.85). CONCLUSIONS: RSNCs show high rates of subsequent disease progression and mortality. This study demonstrated that negative margins may be associated with improved PFS and OS in carefully selected patients who have undergone salvage surgery for RSNC.

New interinstitutional, multimodal presurgical evaluation protocol associated with improved seizure freedom for poorly defined cases of focal epilepsy in children.

OBJECTIVE: In an attempt to improve postsurgical seizure outcomes for poorly defined cases (PDCs) of pediatric focal epilepsy (i.e., those that are not visible or well defined on 3T MRI), the authors modified their presurgical evaluation strategy. Instead of relying on concordance between video-electroencephalography and 3T MRI and using functional imaging and intracranial recording in select cases, the authors systematically used a multimodal, 3-tiered investigation protocol that also involved new collaborations between their hospital, the Montreal Children's Hospital, and the Montreal Neurological Institute. In this study, the authors examined how their new strategy has impacted postsurgical outcomes. They hypothesized that it would improve postsurgical seizure outcomes, with the added benefit of identifying a subset of tests contributing the most. METHODS: Chart review was performed for children with PDCs who underwent resection following the new strategy (i.e., new protocol [NP]), and for the same number who underwent treatment previously (i.e., preprotocol [PP]); ≥ 1-year follow-up was required for inclusion. Well-defined, multifocal, and diffuse hemispheric cases were excluded. Preoperative demographics and clinical characteristics, resection volumes, and pathology, as well as seizure outcomes (Engel class Ia vs > Ia) at 1 year postsurgery and last follow-up were reviewed. RESULTS: Twenty-two consecutive NP patients were compared with 22 PP patients. There was no difference between the two groups for resection volumes, pathology, or preoperative characteristics, except that the NP group underwent more presurgical evaluation tests (p < 0.001). At 1 year postsurgery, 20 of 22 NP patients and 10 of 22 PP patients were seizure free (OR 11.81, 95% CI 2.00-69.68; p = 0.006). Magnetoencephalography and PET/MRI were associated with improved postsurgical seizure outcomes, but both were highly correlated with the protocol group (i.e., independent test effects could not be demonstrated). CONCLUSIONS: A new presurgical evaluation strategy for children with PDCs of focal epilepsy led to improved postsurgical seizure freedom. No individual presurgical evaluation test was independently associated with improved outcome, suggesting that it may be the combined systematic protocol and new interinstitutional collaborations that makes the difference rather than any individual test.

Comorbidities and Medical Complications in Hospitalized Subarachnoid Hemorrhage Patients.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) remains a devastating condition with a case fatality of 36% at 30 days. Risk factors for mortality in SAH patients include patient demographics and the severity of the neurological injury. Pre-existing conditions and non-neurological medical complications occurring during the index hospitalization are also risk factors for mortality in SAH. The magnitude of the effect on mortality of pre-existing conditions and medical complications, however, is less well understood. In this study, we aim to determine the effect of pre-existing conditions and medical complications on SAH mortality. METHODS: For a 25% random sample of the Greater Montreal Region, we used discharge abstracts, physician billings, and death certificate records, to identify adult patients with a new diagnosis of non-traumatic SAH who underwent cerebral angiography or surgical clipping of an aneurysm between 1997 and 2014. RESULTS: The one-year mortality rate was 14.76% (94/637). Having ≥3 pre-existing conditions was associated with increased one-year mortality OR 3.74, 95% CI [1.25, 9.57]. Having 2, or ≥3 medical complications was associated with increased one-year mortality OR, 2.42 [95% CI 1.25-4.69] and OR, 2.69 [95% CI 1.43-5.07], respectively. Sepsis, respiratory failure, and cardiac arrhythmias were associated with increased one-year mortality. Having 1, 2, or ≥3 pre-existing conditions was associated with increased odds of having medical complications in hospital. CONCLUSIONS: Pre-existing conditions and in-hospital non-neurological medical complications are associated with increased one-year mortality in SAH. Pre-existing conditions are associated with increased medical complications.

Clinical Characterization of Traumatic Acute Interhemispheric Subdural Hematoma.

OBJECT: Interhemispheric subdural hematomas (IHSDHs) are thought to be rare. Surgical management of these lesions presents a challenge as they are in close proximity to the sagittal sinus and bridging veins. IHSDHs are poorly characterized clinically and their exact incidence is unknown. There are also no clear guidelines for the management of IHSDH. METHODS: This is a retrospective review of all admitted patients with a diagnosis of traumatic brain injury over a 4-year period at a Level I trauma centre. Clinical characteristics of all patients with subdural hematoma (SDH) and IHSDH were collected. RESULTS: Of 2165 admissions, 1182 patients had acute traumatic SDHs, 420 patients had IHSDHs (1.9% of admissions and 35.5% of SDH), 35 (8.3% of IHSDH) were ≥8 mm in width. IHSDH was isolated in 16 (3.8%) of the cases. Average age was 61.7 ± 21.5 years for all IHSDHs and 77.1 ± 10.4 for large IHSDH (p < 0.001). For large IHSDH, a transient loss of consciousness (LOC) occurred in 51.5% of individuals, post-traumatic amnesia (PTA) in 47.8% of cases, and motor weakness in 37.9% of patients. Five of the large IHSDH patients presented with motor deficits directly related to the IHSDH, and weakness resolved in four of these five individuals. None were treated surgically. Progression of IHSDH width occurred in one patient. CONCLUSION: IHSDHs are often referred to as rare entities. Our results show they are common. Conservative management is appropriate to manage most IHSDHs, as most resolve spontaneously, and their symptoms resolve as well.

Optimal Bone Flap Size for Decompressive Craniectomy for Refractory Increased Intracranial Pressure in Traumatic Brain Injury: Taking the Patient's Head Size into Account.

BACKGROUND: Decompressive craniectomy (DC) is a widely used treatment for refractory high intracranial pressure (ICP). While the Brain Trauma Foundation guidelines favor large DC, there remains a lack of consensus regarding the optimal size of DC in relationship to the patient's head size. The aim of this study is to determine the optimal size of DC to effectively control refractory ICP in traumatic brain injury and to measure that size with a method that takes into consideration the patient's head size. METHODS: All cases of unilateral DC performed to control refractory increased ICP due to cerebral edema during a 7½-year period were included. Demographic and injury-related data were collected by retrospective chart review. The patients were categorized in 2 groups: 21 patients with a "small flaps" and 9 patients with a "large flap." RESULTS: Two groups had similar preoperative characteristics. The amount of cerebrospinal fluid drained and the doses of hyperosmolar therapy given were not different between the 2 groups. The postoperative ICP was significantly lower for the large craniectomy flap group: 13.3 mm Hg confidence interval 99% [12.7, 13.8] versus 16.9 mm Hg confidence interval 99% [16.5, 17.2] (P = 0.01), and this difference was maintained for 96 hours postoperatively. CONCLUSIONS: Better ICP control was achieved in patients who underwent a large decompressive craniectomy (ratio >65%) when compared with smaller craniectomy sizes. The proposed method of measuring the craniectomy size, to our knowledge, is the first to take into account the patient's head size and can be easily measured intraoperatively.

Significance of FDG-PET Hypermetabolism in Children with Intractable Focal Epilepsy.

BACKGROUND: Interictal 18F-fluorodeoxyglucose-positron emission topography (FDG-PET) hypometabolism is routinely used in the presurgical workup of children with medically intractable epilepsy (MIE). FDG-PET hypermetabolism, however, is rarely seen, and the significance of this finding in the epilepsy workup is not well established. METHODS: We performed a retrospective study of patients who underwent FDG-PET during the presurgical workup of MIE over a 4-year period, between 1 January 2010 and 31 December 2013, at the Children's Hospital Colorado, CO, USA. RESULTS: Focal FDG-PET hypermetabolism was identified in 7 (2.2%) of 317 patients. The median age was 124 months, all cases with catastrophic epilepsy. Surface electroencephalography (EEG) performed concomitantly with FDG injections revealed ictal EEG discharges in 2 patients, frequent interictal epileptiform discharges (IEDs) in 3, occasional IEDs in 1, and no IEDs in 1. All 7 patients underwent functional hemispherectomies. Histopathology revealed type 1 focal cortical dysplasia in all patients. Six (86%) were completely seizure-free (Engel class I) and 1 had extremely infrequent seizures (Engel class II) (mean follow-up, 47.4 months). CONCLUSION: While a rare finding, interictal PET hypermetabolism does occur, may help identify epileptogenic zones, and assessment to reveal it should be made by concomitant use of surface EEG during PET scans.

Preoperative Embolization and Complete Tumoral Resection of a Cervical Aggressive Epithelioid Osteoblastoma.

BACKGROUND: Epithelioid "aggressive" osteoblastoma (EOB) is a rare and more aggressive subtype of osteoblastoma (OB) with a higher recurrence rate, greater risk of malignant transformation, larger size, and greater intraoperative blood loss. The present case report illustrates that preoperative angioembolization of an EOB can be safely performed with low intraoperative blood loss. CASE DESCRIPTION: A 21-year-old male patient presented to our institution with a 4-month history of neck discomfort, radicular pain in the proximal right arm, and mild weakness of the right biceps and triceps muscles. Imaging was suggestive of EOB, and computed tomography-guided biopsy confirmed the diagnosis. The patient underwent same-day preoperative angioembolization of the major feeding vessels and subsequent complete tumor resection. During the procedure, he experienced minimal blood loss and did not require blood transfusion. CONCLUSIONS: EOB is a highly vascular primary bony lesion. To minimize intraoperative blood loss, preoperative angioembolization should be considered in the treatment of cervical spine EOB.