ABSTRACT
BACKGROUND: Advances in our understanding of the molecular biology of meningiomas have led to significant gains in the ability to predict patient prognosis and tumor recurrence and to identify novel targets for therapeutic design. Specifically, classification of meningiomas based on DNA methylation has greatly improved our ability to risk stratify patients, however new questions have arisen in terms of the underlying impact these DNA methylation signatures have on meningioma biology. METHODS: This study utilizes RNA-seq data from 486 meningioma samples corresponding to three meningioma DNA methylation groups (Merlin-intact, Immune-enriched, and Hypermitotic), followed by in vitro experiments utilizing human meningioma cell lines. RESULTS: We identify alterations in RNA splicing between meningioma DNA methylation groups including individual splicing events that correlate with Hypermitotic meningiomas and predict tumor recurrence and overall patient prognosis and compile a set of splicing events that can accurately predict DNA methylation classification based on RNA-seq data. Furthermore, we validate these events using RT-PCR in patient samples and meningioma cell lines. Additionally, we identify alterations in RNA binding proteins and splicing factors that lie upstream of RNA splicing events, including upregulation of SRSF1 in Hypermitotic meningiomas which we show drives alternative RNA splicing changes. Finally, we design splice switching antisense oligonucleotides to target RNA splicing changes in NASP and MFF observed in Hypermitotic meningiomas, providing a rationale for RNA-based therapeutic design. CONCLUSIONS: RNA splicing is an important driver of meningioma phenotypes that can be useful in prognosticating patients and as a potential exploit for therapeutic vulnerabilities.
ABSTRACT
BACKGROUND: Dorsal thoracic arachnoid web is a rare diagnosis and is not commonly seen in neurosurgical practice. Patients can present with symptoms and signs of thoracic myelopathy in the setting of an arachnoid cyst and a presyrinx state. OBSERVATIONS: A 57-year-old male with a 10-year history of worsening bilateral leg weakness and chronic back pain re-presented to the neurosurgery clinic after being seen by neurology and orthopedic spine surgery. Initial imaging was concerning for myelomalacia and syringomyelia, and repeat delayed computed tomography myelography findings were consistent with an evolving thoracic arachnoid web, now demonstrating spinal cord compression secondary to arachnoid cyst formation and consistent with the signs of thoracic myelopathy. Intraoperative ultrasound displayed the arachnoid web as the cause of the evolving arachnoid cyst, edematous spinal cord, and a presyrinx-like state. The patient underwent surgical decompression, which restored cerebrospinal fluid (CSF) dynamics, resulting in clinical improvement. LESSONS: Dorsal thoracic arachnoid web is a dynamic condition that can occur in the setting of an arachnoid cyst. There appears to be a relationship between dorsal thoracic arachnoid web formation and the presence of an arachnoid cyst resulting from a ball-valve mechanism leading to the creation of a pressure gradient effect that alters CSF fluid dynamics. https://thejns.org/doi/10.3171/CASE24313.
ABSTRACT
This article reviews the major devices, individuals, and other historical landmarks in the development of suction in the field of neurosurgery, where the operating fields are characteristically deep and narrow. Our review spans the 159 years since the first use of aspiration in surgery to modern applications. This report exemplifies a comprehensive history of suction, the minute iteration of devices, and the massive impact this technological development has had on medicine and neurosurgery.
ABSTRACT
Diagnostic evaluation of a patient with dizziness or vertigo is complicated by a lack of standardized nomenclature, significant overlap in symptom descriptions, and the subjective nature of the patient's symptoms. Although dizziness is an imprecise term often used by patients to describe a feeling of being off-balance, in many cases dizziness can be subcategorized based on symptomatology as vertigo (false sense of motion or spinning), disequilibrium (imbalance with gait instability), presyncope (nearly fainting or blacking out), or lightheadedness (nonspecific). As such, current diagnostic paradigms focus on timing, triggers, and associated symptoms rather than subjective descriptions of dizziness type. Regardless, these factors complicate the selection of appropriate diagnostic imaging in patients presenting with dizziness or vertigo. This document serves to aid providers in this selection by using a framework of definable clinical variants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Subject(s)
Dizziness , Societies, Medical , Dizziness/diagnostic imaging , Humans , United States , Ataxia/diagnostic imaging , Evidence-Based Medicine , Diagnosis, DifferentialABSTRACT
BACKGROUND: Endovascular therapy (EVT) dramatically improves clinical outcomes for patients with anterior circulation emergent large vessel occlusion (ELVO) strokes. With recent publication of two randomized controlled trials in favor of EVT for basilar artery occlusions, the Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee provides this focused update for the existing SNIS guideline, 'Current endovascular strategies for posterior circulation large vessel occlusion stroke.' METHODS: A structured literature review and analysis of studies related to posterior circulation large vessel occlusion (basilar or vertebral artery) strokes treated by EVT was performed. Based on the strength and quality of the evidence, recommendations were made by consensus of the writing committee, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS: Based on the results of the most recent randomized, controlled trials on EVT for basilar or vertebral artery occlusion, the expert panel agreed on the following recommendations. For patients presenting with an acute ischemic stroke due to an acute basilar or vertebral artery occlusion confirmed on CT angiography, National Institutes of Health Stroke Scale (NIHSS) score of ≥6, posterior circulation Alberta Stroke Program Early CT Score (PC-ASPECTS) ≥6, and age 18-89 years: (1) thrombectomy is indicated within 12 hours since last known well (class I, level B-R); (2) thrombectomy is reasonable within 12-24 hours from the last known well (class IIa, level B-R); (3) thrombectomy may be considered on a case by case basis for patients presenting beyond 24 hours since last known well (class IIb, level C-EO). In addition, thrombectomy may be considered on a case by case basis for patients aged <18 years or >89 years on a case by case basis (class IIb, level C-EO). CONCLUSIONS: The indications for EVT of ELVO strokes continue to expand and now include patients with basilar artery occlusion. Further prospective, randomized controlled trials are warranted to elucidate the efficacy and safety of EVT in populations not included in this set of recommendations, and to confirm long term outcomes.
Subject(s)
Endovascular Procedures , Vertebrobasilar Insufficiency , Aged , Aged, 80 and over , Humans , Arterial Occlusive Diseases/surgery , Arterial Occlusive Diseases/therapy , Arterial Occlusive Diseases/diagnostic imaging , Basilar Artery/diagnostic imaging , Basilar Artery/surgery , Endovascular Procedures/methods , Endovascular Procedures/standards , Practice Guidelines as Topic/standards , Thrombectomy/methods , Vertebrobasilar Insufficiency/surgery , Vertebrobasilar Insufficiency/diagnostic imaging , Vertebrobasilar Insufficiency/therapy , Adolescent , Young Adult , Adult , Middle AgedABSTRACT
BACKGROUND: Intracranial aneurysms are prevalent, particularly with advancing age. De novo aneurysms, occurring independently from the initial lesion, pose a unique challenge because of their unpredictable nature. Although risk factors such as female sex, smoking history, and hypertension have been proposed, the mechanisms underlying de novo aneurysm development remain unclear. OBSERVATIONS: A 79-year-old female developed a de novo saccular aneurysm within a year after management of a ruptured vertebral artery dissecting aneurysm. Her complex clinical course involved subarachnoid hemorrhage with diffuse vasospasm, stent occlusion of a dissecting aneurysm, discovery of a right 7- to 8-mm de novo middle cerebral artery aneurysm at the 1-year magnetic resonance angiography follow-up, and successful coil embolization. LESSONS: This rare occurrence challenges established timelines, as most de novo aneurysms manifest over a longer interval. Studies have attempted to identify risk factors, yet consensus remains elusive, particularly regarding the influence of treatment modality on de novo formation rates. This unique case urges reconsideration of posttreatment surveillance protocols, proposing shorter intervals for imaging and more vigilant follow-up strategies to detect asymptomatic de novo aneurysms. Timelier identification could significantly impact patient outcomes by averting potential ruptures. This emphasizes the need for further research to delineate effective monitoring and preventive measures for these enigmatic lesions.
ABSTRACT
BACKGROUND: Early clinical trials validating endovascular therapy (EVT) for emergent large vessel occlusion (ELVO) ischemic stroke in the anterior circulation initially focused on patients with small or absent completed infarctions (ischemic cores) to maximize the probability of detecting a clinically meaningful and statistically significant benefit of EVT. Subsequently, real-world experience suggested that patients with large core ischemic strokes (LCS) at presentation may also benefit from EVT. Several large, retrospective, and prospective randomized clinical trials have recently been published that further validate this approach. These guidelines aim to provide an update for endovascular treatment of LCS. METHODS: A structured literature review of LCS studies available since 2019 and grading the strength and quality of the evidence was performed. Recommendations were made based on these new data by consensus of the authors, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS: The management of ELVO strokes with large ischemic cores continues to evolve. The expert panel agreed on several recommendations: Recommendation 1: In patients with anterior circulation ELVO who present within 24 hours of last known normal with large infarct core (70-149 mL or ASPECTS 3-5) and meet other criteria of RESCUE-Japan LIMIT, SELECT2, ANGEL-ASPECT, TESLA, TENSION, or LASTE trials, thrombectomy is indicated (Class I, Level A). Recommendations 2-7 flow directly from recommendation 1. Recommendation 2: EVT in patients with LCS aged 18-85 years is beneficial (Class I, Level A). Recommendation 3: EVT in patients with LCS >85 years of age may be beneficial (Class I, Level B-R). Recommendation 4: Patients with LCS and NIHSS score 6-30 benefit from EVT in LCS (Class I, Level A). Recommendation 5: Patients with LCS and NIHSS score <6 and >30 may benefit from EVT in LCS (Class IIa, Level A). Recommendation 6: Patients with LCS and low baseline mRS (0-1) benefit from EVT (Class I, Level A). Recommendation 7: Patients with LCS and time of last known well 0-24 hours benefit from EVT (Class I, Level A). Recommendation 8: It is recommended that patients with ELVO LCS who also meet the criteria for on-label or guideline-directed use of IV thrombolysis receive IV thrombolysis, irrespective of whether endovascular treatments are being considered (Class I, Level B-NR). CONCLUSIONS: The indications for endovascular treatment of ELVO strokes continue to expand and now include patients with large ischemic cores on presentation. Further prospective randomized studies, including follow-up to assess the population-based efficacy of treating patients with LCS, are warranted.
ABSTRACT
BACKGROUND: Many patients with transverse myelitis suffer from sensory loss below the spinal level of the lesion. This is commonly associated with chronic neuropathic pain. However, the presence of somatic pain below a complete thoracic sensory level after transverse myelitis is exceptionally rare, and it is unclear if surgical decompression is an effective form of treatment for these patients. CASE PRESENTATION: In this report, we describe a 22-year-old Caucasian female who suffered from chronic lumbar back pain despite a complete thoracic sensory level secondary to prior transverse myelitis. Imaging demonstrated multilevel central stenosis below the sensory level, and her pain improved after surgical decompression. To our knowledge, this is the first reported case of symptomatic lumbar stenosis below a sensory level after transverse myelitis successfully treated with surgical decompression. CONCLUSION: This is the first reported case of a patient with symptomatic lumbar stenosis after transverse myelitis whose lower back pain and quality of life improved following surgical decompression and fusion. This case provides evidence that typical lumbago is possible in patients with sensory loss from transverse myelitis, and standard lumbar decompression may provide benefit for these patients.
Subject(s)
Low Back Pain , Myelitis, Transverse , Spinal Fusion , Spinal Stenosis , Humans , Female , Young Adult , Adult , Spinal Stenosis/complications , Spinal Stenosis/diagnostic imaging , Spinal Stenosis/surgery , Constriction, Pathologic/complications , Myelitis, Transverse/complications , Myelitis, Transverse/diagnostic imaging , Myelitis, Transverse/surgery , Quality of Life , Back Pain/etiology , Back Pain/surgery , Low Back Pain/etiology , Decompression, Surgical/methods , Lumbar Vertebrae/diagnostic imaging , Lumbar Vertebrae/surgery , Spinal Fusion/methods , Treatment OutcomeABSTRACT
BACKGROUND: Sir Rickman John Godlee (1849-1925) was widely known for performing the first documented surgery to resect a tumor from the brain. METHODS: The case was performed on November 25, 1884, on a 25-year-old farmer who presented with a left-sided Jacksonian March seizure. RESULTS: The case was highly publicized because the tumor was localized by Dr. Hughes Bennett and subsequently resected by Sir Godlee based on the patient's clinical presentation and physical examination alone. CONCLUSIONS: Aside from this widely publicized case, little has been written about Sir Godlee. Sir Godlee was also known to be an outstanding anatomist who displayed exceptional skills in surgical dissection. He was known for being an excellent teacher. Sir Godlee was deeply influenced by his uncle, Lord Joseph Lister, a renowned physician who popularized antiseptic methods. Sir Godlee was also known for publishing his uncle's biography, Lord Lister.
Subject(s)
Brain Neoplasms , Male , Humans , Adult , Brain Neoplasms/surgery , Seizures , Dissection , Family , Physical ExaminationABSTRACT
BACKGROUND: Esthesioneuroblastoma (ENB) is a rare neoplasm of the sinonasal tract. Currently, the optimal treatment includes maximal resection combined with radiotherapy and/or chemotherapy. Although ENBs often recur and have an aggressive clinical course, spinal metastases are extremely rare and the underlying molecular mechanisms are poorly understood. OBSERVATIONS: Here, the authors describe a 50-year-old male with an aggressive ENB, initially treated with resection and chemotherapy/radiation, who developed multiple thoracic and lumbar spinal metastases. The authors performed targeted exome sequencing on both the resected primary tumor and biopsied spinal metastases, which revealed 12 total variants of unknown clinical significance in genes associated with the PI3K/AKT/mTOR pathway, chromatin remodeling, DNA repair, and cell proliferation. Six of these variants were restricted to the metastatic lesion and included missense mutations with predicted functional effects in GRM3, DNMT3B, PLCG2, and SPEN. LESSONS: This report discusses the potential impact of these variants on tumor progression and metastasis, as well as the implications for identifying potential new biomarkers and therapies.
ABSTRACT
Antiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline 'Platelet function inhibitor and platelet function testing in neurointerventional procedures', providing updates based on the treatment of specific pathologies and for patients with specific comorbidities
Subject(s)
Humans , Intracranial Arterial Diseases/drug therapy , Platelet Aggregation Inhibitors/therapeutic use , Fibrinolytic Agents/therapeutic useABSTRACT
OBJECTIVE: Recruitment of diverse and talented students to the field of neurosurgery is key to its continued growth and scientific advancement. Barriers, including poor perceptions and lack of early exposure, can impact recruitment and have been compounded by the ongoing COVID-19 pandemic. This study examines the impact of an inaugural Neurosurgery Research Consortium meeting on premedical students, assessing whether this exposure generated interest and improved perceptions of a career in neurosurgery. METHODS: Premedical students were recruited to virtually attend an inaugural Neurosurgery Research Consortium developed by the affiliated medical school's American Association of Neurological Surgeons (AANS) Student Chapter. Questionnaires were distributed to students before and after the meeting to assess student demographics and perceptions of neurosurgery. RESULTS: A total of 54 students attended the meeting, with general interest in neurosurgery, medicine, and research opportunities being the primary factors for attendance. Following the research meeting, we found that students perceived neurosurgeons to be friendlier and more approachable, with a more positive quality of life (QoL). Overall perceptions of neurosurgery improved after the meeting, but perceptions among racial and ethnic minority students did not significantly change in the areas of diversity, inclusion, and equity. CONCLUSIONS: These results suggest recruitment strategies targeting undergraduate students may improve their perception of neurosurgery as a career, and may mitigate some barriers to entry. These strategies are cost effective and easily replicable, making an easily implementable approach to provide direct insight into neurosurgery for future medical students while also promoting academic efforts in the field of neurosurgery.
Subject(s)
Neurosurgery , Students, Medical , Humans , United States , Neurosurgery/education , Quality of Life , Ethnicity , Pandemics , Students, Premedical , Career Choice , Minority Groups , Surveys and QuestionnairesABSTRACT
OBJECTIVE: The All Patients Refined Diagnosis Related Group (APR-DRG) modifiers-severity of illness (SOI) and risk of mortality (ROM)-inform hospital reimbursement nationally. The ubiquitous APR-DRG data bear the potential to inform public health research; however, the algorithms that generate these modifiers are proprietary and therefore should be independently verified. This study evaluated the predictive value of APR-DRG modifiers for the outcomes and costs of intracranial hemorrhage. METHODS: The New York Statewide Planning and Research Cooperative System databases were accessed and searched for the intracranial hemorrhage Diagnosis Related Group in records from 2012 to 2020. Receiver operating characteristic and multiple logistic regressions characterized the predictive validity of the APR-DRG modifiers for patient outcomes. One-way ANOVA compared costs and charges between SOI and ROM designations. RESULTS: Among 46,019 patients, 12,627 (27.4%) died. The mean ± SEM costs per patient were $21,342 ± $145 and the mean ± SEM charges per patient were $68,117 ± $408. For prediction of mortality, the area under the curve (AUC) was 0.74 for SOI and 0.83 for ROM. For prediction of discharge to a facility, AUC was 0.62 for SOI and 0.64 for ROM. Regression analysis showed that ROM was a strong predictor of mortality, while SOI was a weak predictor; both were modest predictors of discharge to a facility. SOI and ROM were significant predictors of costs and charges. CONCLUSIONS: Compared with the prior studies, the authors identified several limitations of APR-DRG modifiers, including low specificity, modest AUC, and limited outcomes prediction. This report supports the limited use of APR-DRG modifiers in independent research on intracranial hemorrhage epidemiology and reimbursement and advocates for general caution in their use for evaluation of neurosurgical disease.
Subject(s)
Algorithms , Hospitals , Humans , Prognosis , Intracranial Hemorrhages/diagnosis , Diagnosis-Related Groups , Retrospective Studies , Length of StayABSTRACT
BACKGROUND: Antiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline 'Platelet function inhibitor and platelet function testing in neurointerventional procedures', providing updates based on the treatment of specific pathologies and for patients with specific comorbidities. METHODS: We performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS: The management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6-12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual's ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient's risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R). CONCLUSIONS: Although the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.
ABSTRACT
BACKGROUND: Limited literature exists on the morbidity and mortality of AVM associated intracerebral hemorrhage (ICH) compared with non-AVM ICH. OBJECTIVE: We examine morbidity and mortality in cAVM in a large nationwide inpatient sample to create a prognostic inpatient ruptured AVM mortality score. METHODS: This retrospective cohort study from 2008 to 2014 compares outcomes in cAVM related hemorrhages and ICH utilizing the National Inpatient Sample database. Diagnostic codes for ICH and AVM underlying ICH were identified. We compared case fatality according to medical complications. Multivariate analysis was used to derive hazard ratios and 95% confidence intervals to assess odds of mortality. RESULTS: We identified 6496 patients with ruptured AVMs comparing them to 627,185 admitted with ICH. Mortality was lower for ruptured AVMs (11%) compared to ICH (22%) [p < 0.01]. Mortality associated factors were liver disease (OR 2.64, CI 1.81-3.85, p < .001), diabetes mellitus (OR 2.42, CI 1.38-4.22, p = 0.002), alcohol abuse (OR 1.81, CI 1.31-2.49, p = 0.001), hydrocephalus (OR 3.35 CI 2.81-4.00, p < 0.001), cerebral edema (OR 1.5, 1.25-1.85, p < 0.001), cardiac arrest (OR 15, CI 7.9-30, p < 0.001), and pneumonia (OR 1.93, CI 1.51-2.47, p < 0.001). A 0-5 ruptured AVM mortality score was developed: Cardiac arrest (=3), age >60 (=1), Black race (=1), chronic liver failure (=1) diabetes mellitus (=1), pneumonia (=1), alcohol abuse (=1) and cerebral edema (=1). Mortality increased with score. No patient with 5 or more points survived. CONCLUSION: The Ruptured AVM Mortality Score allows for risk stratification on patients with ICH due to ruptured AVM. This scale could prove useful in prognostication and patient education.
ABSTRACT
Middle meningeal artery embolization (MMAE) for chronic subdural hematomas (cSDHs) has evolved as a potential treatment alternative for these lesions. The indications for using this treatment modality and the pathophysiology of cSDHs are an area of considerable interest. A retrospective review was performed including all major papers addressing this topic. Although considered a relatively new treatment option, MMAE for cSDHs is gaining widespread popularity. There are many questions that need to be addressed regarding its indications, some of which are the subject of ongoing clinical trials. The efficacy of this treatment modality in carefully selected patients has also provided new insights into the potential pathophysiology of cSDHs. This concise review will focus on the current evidence supporting the use of embolization in the treatment of this disease and highlight unanswered relevant clinical questions regarding MMAE indications and technique.
Subject(s)
Embolization, Therapeutic , Hematoma, Subdural, Chronic , Humans , Hematoma, Subdural, Chronic/therapy , Meningeal Arteries , Embolization, Therapeutic/methods , Retrospective StudiesABSTRACT
BACKGROUND: Meningiomas are the most common intracranial tumors. Recent advancements in the genetic profiling of tumors have allowed information including DNA copy number analysis, mutational analysis, and RNA sequencing to be more frequently reported, in turn allowing better characterization of meningiomas. In recent years, analysis of tumor methylomes that reflects both cell-origin methylation signatures and somatically acquired DNA methylation changes has been utilized to better classify meningiomas with great success. METHOD: We report DNA methylation profiling on meningiomas from 17 patients. Formalin-fixed paraffin-embedded (FFPE) meningioma tumor samples were processed, loaded onto the Infinium Methylation EPIC array, and scanned using the Illumina IScan system. Raw IDAT files were processed through the the CNS tumor classifier developed by the Molecular Neuropathology group at the German Cancer Research Center (DKFZ). Corresponding genomics were captured using targeted sequencing panels. RESULT: Among the meningioma samples, 13 samples were classified as "benign," two samples as "intermediate," and the remaining three samples (from two patients) as "malignant," based on previously validated classification algorithms. In addition to tumor methylation profiling, we also present information that includes patient demographics, clinical presentations, tumor characteristics (including size and location), surgical approaches, and mutational analysis. The two patients who provided the samples with "malignant" methylation classifications had tumor recurrence, reflecting a more aggressive disease course. CONCLUSION: In accordance with prior reports, our case series provides support that tumor DNA methylation profiling adds meaningful classification information and may be beneficial to incorporate in clinical practice. Our report also reveals that DNA methylation combined with WHO histology classification can more accurately predict tumor behavior than WHO classification alone.