Patterns of seizure spread in temporal lobe epilepsy are associated with distinct white matter tracts.

OBJECTIVE: It is commonly hypothesized that seizure spread patterns in patients with focal epilepsy are associated with structural brain pathways. However, this relationship is poorly understood and has not been fully demonstrated in patients with temporal lobe epilepsy. Here, we sought to determine whether directionality of seizure spread (DSS) is associated with specific cerebral white matter tracts in patients with temporal lobe epilepsy. METHODS: Thirty-three adult patients with temporal lobe epilepsy who underwent stereoelectroencephalography (sEEG) and magnetic resonance diffusion tensor imaging (MR-DTI) as part of their standard-of-care clinical evaluation were included in the study. DSS was defined as anterior-posterior (AP) or medial-lateral (ML) spread based upon sEEG evaluation by two independent specialists who demonstrated excellent inter-rater agreement (Cohen's kappa = .92). DTI connectometry was used to assess differences between seizure spread pattern groups along major fiber pathways regarding fractional anisotropy (FA). RESULTS: Twenty-four participants showed seizures with AP spread and nine participants showed seizures with ML spread. There were no significant differences between the groups on their demographic and clinical profile. Patients with ML seizures had higher FA along the corpus callosum and, to a lesser degree, some portions of the bilateral cingulate tracts. In contrast, patients with AP seizures had higher FA along several anterior-posterior white matter projections bundles, including the cingulate fasciculus and the inferior longitudinal, with significantly less involvement of the corpus callosum compared with ML seizures. SIGNIFICANCE: This study confirms the hypothesis that the anatomical pattern of electrophysiological ictal propagation is associated with the structural reinforcement of supporting pathways in temporal lobe epilepsy. This observation can help elucidate mechanisms of ictal propagation and may guide future translational approaches to curtail seizure spread.

Successful repair of intraoperative cerebrospinal fluid leaks improves outcomes in endoscopic skull base surgery.

BACKGROUND: The impact of failed cerebrospinal fluid leak (CSF) leak repair in endoscopic skull base surgery has not been adequately studied. METHODS: In this investigation we reviewed patients who had undergone endoscopic skull base surgery between 2002 and 2014 at 7 international centers. Demographic variables, comorbidities, tumor characteristics, and repair techniques were evaluated to determine association with successful repair of CSF leak. Postoperative complications and length of stay were compared among groups. RESULTS: Data were collected on 2097 patients who were divided into 3 groups: (1) those with no intraoperative leak (n = 1533); (2) those with successful repair of their intraoperative leak (n = 452); and (3) those with failed repair (n = 112). Compared with successful repair, failed repair was associated with an increased risk of intracranial infection (odds ratio [OR], 5.6; 95% confidence interval [CI], 5.3-13.15), pneumocephalus (OR, 16; 95% CI, 5.8-44.4), 30-day readmission (OR, 8.4; 95% CI, 5.3-13.5), reoperation (OR, 115.4; 95% CI, 56.3-236.8), and prolonged hospital stay (14.9 vs 7.0 days, p < 0.01). Outcomes in patients who had successful repairs of intraoperative leaks were similar to those who never had leakage. Intraoperative use of pedicled nasoseptal flaps was associated with successful repair (OR, 0.60; 95% CI, 0.34-0.92). CONCLUSION: Intraoperative CSF leaks are a frequent and expected occurrence during endoscopic skull base surgery. Failed CSF leak repair has a significant impact on patient outcomes, with increased rates of postoperative pneumocephalus, intracranial infections, reoperation, deep vein thrombosis, readmission, and prolonged hospital stay. Recognition and repair of intraoperative CSF leaks reduces postoperative complications. Use of pedicled nasoseptal flaps improves outcomes in reconstructing defects at higher risk for postoperative leak.

Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery.

BACKGROUND: In patients undergoing transnasal endoscopic sellar surgery, an analysis of risk factors and predictors of intraoperative and postoperative cerebrospinal fluid leak (CSF) would provide important prognostic information. METHODS: A retrospective review of patients undergoing endoscopic sellar surgery for pituitary adenomas or craniopharyngiomas between 2002 and 2014 at 7 international centers was performed. Demographic, comorbidity, and tumor characteristics were evaluated to determine the associations between intraoperative and postoperative CSF leaks. Correlations between reconstructive and CSF diversion techniques were associated with postoperative CSF leak rates. Odds ratios (OR) were identified using a multivariate logistic regression model. RESULTS: Data were collected on 1108 pituitary adenomas and 53 craniopharyngiomas. Overall, 30.1% of patients had an intraoperative leak and 5.9% had a postoperative leak. Preoperative factors associated with increased intraoperative leaks were mild liver disease, craniopharyngioma, and extension into the anterior cranial fossa. In patients with intraoperative CSF leaks, postoperative leaks occurred in 10.3%, with a higher postoperative leak rate in craniopharyngiomas (20.8% vs 5.1% in pituitary adenomas). Once an intraoperative leak occurred, craniopharyngioma (OR = 4.255, p = 0.010) and higher body mass index (BMI) predicted postoperative leak (OR = 1.055, p = 0.010). In patients with an intraoperative leak, the use of septal flaps reduced the occurrence of postoperative leak (OR = 0.431, p = 0.027). Rigid reconstruction and CSF diversion techniques did not impact postoperative leak rates. CONCLUSION: Intraoperative CSF leaks can occur during endoscopic sellar surgery, especially in larger tumors or craniopharyngiomas. Once an intraoperative leak occurs, risk factors for postoperative leaks include craniopharyngiomas and higher BMI. Use of septal flaps decreases this risk.

Multi-institutional study of risk factors for perioperative morbidity following transnasal endoscopic pituitary adenoma surgery.

BACKGROUND: The goal of this study was to identify preoperative risk factors associated with increased perioperative morbidity after endoscopic pituitary surgery. METHODS: A retrospective review of patients undergoing endoscopic pituitary adenoma surgery between 2002 and 2014 at 6 international centers was performed. Standard demographic and comorbidity data, as well as information regarding tumor extent and treatment were collected. Logistic regression was used to examine risk factors for the following 30-day outcomes: systemic complications, intracranial complications, postoperative cerebrospinal fluid (CSF) leaks, length of hospital stay, readmission, and reoperation. RESULTS: Data was collected on 982 patients with a mean age of 52 years. The median body mass index (BMI) for all patients was 30.9 kg/m(2) with 56% female. The median hospital stay was 5 days and 23.8% of patients suffered a postoperative adverse event. Systemic complications occurred in 3.2% of patients and intraventricular extension was a risk factor (odds ratio [OR] 8.9). Intracranial complications occurred in 7.3% of patients and risk factors included previous radiation (OR 8.6) and intraventricular extension (OR 7.9). Reoperation occurred in 6.5% of patients and intraventricular extension (OR 7.3) and age (<40 years, OR 3.5; 40 to 64 years, OR 3.2) were risk factors. Postoperative CSF leaks occurred in 5.5% of patients and risk factors included female gender (OR 2.4), BMI ≥ 30 (OR 2.1), age (<40 years, OR 5.3; 40 to 64 years, OR, 7.9), and intraventricular extension (OR, 9.5). CONCLUSION: Postoperative endoscopic pituitary adenoma surgery complications are associated with tumors with intraventricular extension, preoperative radiation, as well as common patient comorbidities. Identification of these factors may permit implementation of strategies to reduce postoperative complications.

Is sex an independent prognostic factor in esthesioneuroblastoma?

OBJECTIVE: To determine if sex independently affects presentation and disease-specific survival (DSS) in patients with esthesioneuroblastoma (ENB). STUDY DESIGN: A case-control study from the Surveillance Epidemiology and End Results (SEER) data base. METHODS: The assessment identified 611 patients in the SEER data base who were diagnosed with ENB from 1988 to 2010. Data on race, ethnicity, age at diagnosis, sex, histologic grade, radiation treatment status, and surgical treatment status of patients with ENB from 1988 to 2010 were extracted. By using tumor extension data, the modified Kadish stage of each case was determined. The modified Kadish system was able to successfully classify 547 of 611 tumors from 1988 to 2010. Histologic grade, modified Kadish stage and DSS of male patients was compared with the DSS of female patients. RESULTS: Demographic data showed that male patients presented with a significantly higher grade (p < 0.05) and a trend toward a higher stage (p = 0.08). With unmatched data, male patients had significantly worse DSS than female patients (p < 0.05). After case-matching, the difference between the DSS for male versus female patients was no longer significant. CONCLUSIONS: Male patients with ENB seemed to have significantly worse DSS at 10 years than female patients. This disparity seems to be due to higher grade and stage in male patients at presentation. After accounting for these two factors, the prognosis of male patients was not found to be significantly different from that of female patients.

Preliminary study on the stability of beta-2 transferrin in extracorporeal cerebrospinal fluid.

OBJECTIVE: Detection of beta-2 transferrin in rhinorrhea fluid is a sensitive and specific method for the diagnosis of a cerebrospinal fluid (CSF) leak. Patients may be asked to collect this fluid at home to obtain an adequate volume for detection, and thus the age and storage conditions of these specimens may be variable upon analysis. The purpose of this study is to understand how age, storage temperature, and exposure to mucus affect the ability to detect beta-2 transferrin in CSF. STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary care university hospital. SUBJECTS AND METHODS: This study consists of 6 patients undergoing endoscopic CSF leak repair. CSF was collected directly from a lumbar drain (n = 4) or from nasal drainage (n = 2). Specimens were stored at 4°C (n = 3) or room temperature (n = 3). Samples were tested for the presence of beta-2 transferrin for up to 7 days using standard immunofixation electrophoresis techniques. RESULTS: Beta-2 transferrin was detected in all specimens through day 7 regardless of storage temperature or collection site (95% exact binomial confidence interval of 0%-46%). CONCLUSIONS: Beta-2 transferrin remains detectable in extracorporeal CSF for up to 7 days regardless of storage at room temperature or exposure to nasal mucus. Negative detection in patient specimens up to a week old is therefore not likely to be caused by protein degradation.