A brave new framework for glioma drug development.

Patients with brain tumours are motivated to participate in clinical trials involving repeat tissue sampling. Normalising the use of neoadjuvant and staged surgical trials necessitates collaboration among patients, regulatory agencies, and researchers. Initial and repetitive tissue sampling plays a crucial role in enhancing our understanding of resistance mechanisms and vulnerabilities in brain tumour therapy. Standardising biopsy techniques and ensuring technical uniformity across institutions are vital for effective interinstitutional collaboration. Although liquid biopsy technologies hold promise, they are not yet ready to replace tissue analysis. Clear communication about the risks and benefits of biopsies is essential, particularly regarding potential postoperative deficits. Changes in mindset and neurosurgical culture are imperative to achieve much needed breakthroughs in the development of new, effective therapies for brain tumours.

Arnold Max Meirowsky: champion of the American mobile neurosurgical unit during the Korean War.

Dr. Arnold Max Meirowsky (1910-1984) was enormously influential to military neurosurgery during the Korean War, introducing to the American military the concept of the mobile neurosurgical unit. After implementation of the neurosurgical detachment, meningocerebral infections saw a decrease from 41% to less than 1%, with similar improvements in mortality and complication rates. Additionally, Meirowsky developed many techniques and improvements in neurosurgery, specifically in the field of neurosurgical trauma, which he dedicated himself to even after reentering civilian practice. Furthermore, his mentorship of Korean surgeons and the influence of his mobile neurosurgical unit were major influences cited to be pivotal to the founding of neurosurgery as a specialty in South Korea. As he is underrecognized for these accomplishments in the neurosurgical literature, the authors seek to review his wartime and career contributions. They also specifically present details of his standardization of the mobile neurosurgical unit and showcase several of his other advancements in the treatment of neurosurgical trauma.

Conditional Vasospasm-Free Survival Following Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Following aneurysmal subarachnoid hemorrhage (SAH), patients are monitored closely for vasospasm in the intensive care unit. Conditional vasospasm-free survival describes the risk of future vasospasm as a function of time elapsed without vasospasm. Conditional survival has not been applied to this clinical scenario but could improve patient counseling and intensive care unit use. The objective of this study was to characterize conditional vasospasm-free survival following SAH. METHODS: This was a single institution, retrospective cohort study of patients treated for aneurysmal SAH between 1/1/2000-6/1/2020. The primary outcome was the development of vasospasm defined by the first instance of either radiographic vasospasm on computed tomography angiography, Lindegaard Index > 3.0 by transcranial doppler ultrasonography, or vasospasm-specific intraarterial therapy. Multivariable Cox regression was performed, and conditional vasospasm-free survival curves were constructed. RESULTS: A total of 528 patients were treated for aneurysmal SAH and 309 (58.5%) developed vasospasm. Conditional survival curves suggest patients who survive to postbleed day 10 without vasospasm have a nearly 90% chance of being discharged without vasospasm. The median onset of vasospasm was postbleed day 6. Age more than 50 years was associated with a lower risk (hazard ratio [HR] = .76; 95% confidence interval [CI] 0.64-0.91; p < 0.001). Higher initial systolic blood pressure (HR = 1.18; 95% CI 1.046-1.350; p = .008), Hunt-Hess grades 4 or 5 (HR = 1.304; 95% CI 1.014-1.676), and modified Fisher scale score of 4 (HR = 1.808; 95% CI 1.198-2.728) were associated with higher vasospasm than the respective lower grades. CONCLUSION: Conditional survival provides a useful framework for counseling patients and making decisions around vasospasm risk for patients with aneurysmal SAH, while risk factor-stratified plots facilitate a patient-centric, evidence-based approach to these conversations and decisions.

A National Cancer Database analysis of the patterns of care for meningeal melanocytoma.

Aim: To evaluate demographics, treatment patterns, radiotherapy utilization and patient outcomes in meningeal melanocytomas. Materials & methods: The National Cancer Database was queried for meningeal melanocytomas diagnosed in 2002-2016. The effects of demographic, clinical and treatment variables were determined via Kaplan-Meier log-rank and Cox regression analyses. Results: The median and 5-year overall survival were 57.46 months and 48%, respectively. Patients earning ≥$48K showed improved survival (p = 0.0319). Radiotherapy and chemotherapy were utilized in 37.7 and 9% of patients, respectively. Conclusion: Income significantly affected survival. Surgery remains the mainstay approach. Radiotherapy was delivered in more than one-third of patients but did not impact survival. However, further analyses were limited by poor treatment modality information in the database.

Lay abstract Aim: To assess the impact of demographic, clinical and treatment factors on survival in patients with meningeal melanocytomas. Materials & methods: Biostatistical analyses were conducted on patients diagnosed with meningeal melanocytomas between 2002 and 2016 using data from the National Cancer Database. Results: The median and 5-year survival rate were 57.46 months and 48%, respectively. Patients with incomes ≥$48K showed improved survival (p = 0.0319). Radiotherapy and chemotherapy were administered in 37.7 and 9% of patients, respectively. Conclusion: Income was a critical factor in increasing patient survival. Surgery serves as the primary means for treatment, while radiotherapy and chemotherapy remain underutilized.

Image guidance in spine tumor surgery.

Beginning with basic stereotactic operative methods in neurosurgery, intraoperative navigation and image guidance systems have since become the norm in that field. Following the introduction of image guidance into spinal surgery, there has been a dramatic increase in its utilization across disciplines and pathologies. Spine tumor surgery encompasses a wide range of complex surgical techniques and treatment strategies. Similarly to deformity correction and trauma surgery, spine navigation holds potential to improve outcomes and optimize surgical technique for spinal tumors. Recent data demonstrate the applicability of neuro-navigation in the field of spinal oncology, particularly for spinal stabilization, maximizing extent of resection and integration of minimally invasive therapies. The rapid introduction of new, less invasive, and ablative surgical techniques in spine oncology coupled with the rising incidence of spinal metastatic disease make it imperative for spine surgeons to be familiar with the indications for and limitations of imaging guidance. Herein, we provide a practical, current concepts narrative review on the use of spinal navigation in three areas of spinal oncology: (a) extent of tumor resection, (b) spinal column stabilization, and (c) focal ablation techniques.

Enhanced Sensitivity Using MALDI Imaging Coupled with Laser Postionization (MALDI-2) for Pharmaceutical Research.

Visualizing the distributions of drugs and their metabolites is one of the key emerging application areas of matrix-assisted laser desorption/ionization-mass spectrometry imaging (MALDI-MSI) within pharmaceutical research. The success of a given MALDI-MSI experiment is ultimately determined by the ionization efficiency of the compounds of interest, which in many cases are too low to enable detection at relevant concentrations. In this work we have taken steps to address this challenge via the first application of laser-postionisation coupled with MALDI (so-called MALDI-2) to the analysis and imaging of pharmaceutical compounds. We demonstrate that MALDI-2 increased the signal intensities for 7 out of the 10 drug compounds analyzed by up to 2 orders of magnitude compared to conventional MALDI analysis. This gain in sensitivity enabled the distributions of drug compounds in both human cartilage and dog liver tissue to be visualized using MALDI-2, whereas little-to-no signal from tissue was obtained using conventional MALDI. This work demonstrates the vast potential of MALDI-2-MSI in pharmaceutical research and drug development and provides a valuable tool to broaden the application areas of MSI. Finally, in an effort to understand the ionization mechanism, we provide the first evidence that the preferential formation of [M + H]+ ions with MALDI-2 has no obvious correlation with the gas-phase proton affinity values of the analyte molecules, suggesting, as with MALDI, the occurrence of complex and yet to be elucidated ionization phenomena.

Molecular Weight Growth in the Gas-Phase Reactions of Dehydroanilinium Radical Cations with Propene.

Protonated aniline-one of the simplest nitrogen-bearing aromatic molecules-is speculated to be present within Titan's atmosphere, where it could play a role in molecular weight growth chemistry. To investigate this possibility, this paper examines the reactions of propene with distonic radical cations derived from protonated aniline. The reaction kinetics, products, and branching ratios of these distonic radical cations (i.e., 2-, 3-, and 4-dehydroanilinium radical cations) are measured in the gas phase using ion-trap mass spectrometry, and calculations (M06-2X/6-31G(2df,p) and G3X-K) are used to rationalize the results. The reaction efficiencies for the 2-, 3-, and 4-dehydroanilinium radical cations are reported as 30.7 (±3.1)%, 2.4 (±0.5)%, and 2.1 (±0.4)%, respectively (with ±50% absolute accuracy). The 4- and 3-dehydroanilinium radical cations undergo addition of propene followed by either (i) methyl radical loss forming ammonio styrene cations (m/z 120) or (ii) ethylene loss pathways forming the ammonio benzyl radical cation (m/z 107). The 4-dehydroanilinium reaction favors methyl loss over ethylene loss, whereas the reverse is true for 3-dehydroanilinium. In contrast, the 2-dehydroanilinium radical cation reacts with propene to purportedly form amino tropylium cation (m/z 106) with ethyl radical loss and methyl amino tropylium cation (m/z 120) with methyl radical loss. The energies of all minima and transition states leading to predicted dissociation products are below the energy of the initial reactants providing plausible pathways at the low temperatures of Titan's atmosphere.

Highly efficient gas-phase reactivity of protonated pyridine radicals with propene.

Small nitrogen containing heteroaromatics are fundamental building blocks for many biological molecules, including the DNA nucleotides. Pyridine, as a prototypical N-heteroaromatic, has been implicated in the chemical evolution of many extraterrestrial environments, including the atmosphere of Titan. This paper reports on the gas-phase ion-molecule reactions of the three dehydro-N-pyridinium radical cation isomers with propene. Photodissociation ion-trap mass spectrometry experiments are used to measure product branching ratios and reaction kinetics. Reaction efficiencies for 2-dehydro-N-pyridinium, 3-dehydro-N-pyridinium and 4-dehydro-N-pyridinium with propene are 70%, 47% and 41%, respectively. The m/z 106 channel is the major product channel across all cases and assigned 2-, 3-, and 4-vinylpyridinium for each reaction. The m/z 93 channel is also significant and assigned the 2-, 3-, and 4-N-protonated-picolyl radical cation for each case. H-Abstraction from propene is not competitive under experimental conditions. Potential energy schemes, at the M06-2X/6-31(2df,p) level of theory and basis set, are described to assist in rationalising observed product branching ratios and elucidating possible reaction mechanisms. Reaction barriers to the production of vinylpyridinium (m/z 106) + CH3 are the lowest identified for the 3- and 4-dehydro-N-pyridinium reactions, in support of the observed dominance of the m/z 106 ion signal. Ethylene loss via ring-mediated H-transfer along the propyl group is found to be the lowest energy pathway for the 2-dehydro-N-pyridinium reaction, suggesting a preference toward m/z 93 (N-protonated-picolyl radical cation) over the experimentally observed products. Entropic bottle-necks along the m/z 93 pathway however, associated with ring-mediated H-atom transfer, are responsible for the dominance of m/z 106 in the 2-dehydro-N-pyridinium + propene reaction. For all three isomers, computed barriers for all observed reaction channels were below the entrance channel, suggesting these reactions can contribute to molecular weight growth in extraterrestrial environments with accelerated reaction rates in low temperature regions of space.

Resection of a ventral intramedullary spinal cord ependymoma through an anterior cervical approach: illustrative case.

BACKGROUND: Although posterior myelotomy leaves patients with dorsal column deficits, few reports have explored the anterior cervical approach for cervical intramedullary tumors. The authors describe the resection of a cervical intramedullary ependymoma through an anterior approach with a two-level corpectomy and fusion. OBSERVATIONS: A 49-year-old male presented with a C3-5 ventral intramedullary mass with polar cysts. Because of the ventral location of the tumor and the added benefit of avoiding a posterior myelotomy and dorsal column deficits, an anterior C4-5 corpectomy offered a direct route and excellent visualization of the ventrally located tumor. After a C4-5 corpectomy, microsurgical resection, and C3-6 anterior fusion with a fibular allograft filled with autograft, the patient remained neurologically intact. Magnetic resonance imaging (MRI) on postoperative day (POD) 1 confirmed gross-total resection. The patient was extubated on POD 2 and was discharged home on POD 4 with a stable examination. At 9 months, the patient developed mechanical neck pain refractory to conservative treatment and underwent a posterior fusion to address pseudarthrosis. MRI at 15 months showed no evidence of tumor recurrence with the resolution of neck pain. LESSONS: An anterior cervical corpectomy provides a safe corridor to access ventral cervical intramedullary tumors and avoids posterior myelotomy. Although the patient required a three-level fusion, we believe the tradeoff of decreased motion compared to dorsal column deficits is preferred.

Conditional Recurrence-Free Survival After Surgical Resection of Meningioma.

BACKGROUND: Recurrence after meningioma resection warrants serial surveillance imaging, but little evidence guides the optimal time interval between imaging studies/surveillance duration. OBJECTIVE: To describe recurrence-free survival (RFS) after meningioma resection, conditioned to short-term RFS. METHODS: A retrospective cohort study for adults presenting for meningioma resection from 2000 to 2018 was conducted. The primary outcome was postoperative follow-up RFS. Conditional RFS Kaplan-Meier analysis was performed at 1, 2, 3, 5, and 10 years, conditioned to 6-month and 12-month RFS. RFS probabilities conditioned to 6-month RFS were estimated in subgroups, stratified by World Health Organization grade, extent of resection, and need for postoperative radiation. RESULTS: In total, 723 patients were included. Median age at surgery was 57.4 years (IQR = 47.2-67.2). Median follow-up was 23.5 months (IQR = 12.3-47.8). Recurrence was observed in 90 patients (12%), with median time to recurrence of 14.4 months (IQR = 10.3-37.1). Conditioned to 6-month postoperative RFS, patients had 90.3% probability of remaining recurrence-free at 2 years and 69.4% at 10 years. Subgroup analysis conditioned to 6-month RFS demonstrated grade 1 meningiomas undergoing gross total resection (GTR) had 96.0% probability of RFS at 1 year and 82.8% at 5 years, whereas those undergoing non-GTR had 94.5% and 79.9% probability, respectively. RFS probability was 78.8% at 5 years for non-grade 1 meningiomas undergoing GTR, compared with 69.7% for non-grade 1 meningiomas undergoing non-GTR. Patients with non-grade 1 meningiomas undergoing upfront radiation had a 1-year RFS of 90.1% and 5-year RFS of 51.7%. CONCLUSION: Recurrence risk after meningioma resection after an initial recurrence-free period is reported, with high-risk subgroups identified. These results can inform objective shared decision-making for optimal follow-up.

Association between preoperative hematologic markers and aggressive behavior in meningiomas.

INTRODUCTION: Meningiomas have varying degrees of aggressive behavior. Some systemic hematologic makers are associated with malignancy, but their value in predicting aggressive meningioma behavior is not fully understood. OBJECTIVE: To evaluate the association between preoperative markers such as neutrophil-lymphocyte ratio (NLR), neutrophil-monocyte ratio (NMR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), and prognostic nutritional index (PNI), and diagnostic and prognostic factors including WHO grade, proliferation index, presence of edema on preoperative MRI, and tumor recurrence. METHODS: A retrospective review of patients treated between 2000 and 2019 with a preoperative complete blood count (CBC) differential lab draw before intracranial meningioma resection was conducted. All preoperative steroid dosages were converted to dexamethasone equivalents. Primary outcomes included presence/absence of perilesional edema, WHO grade, Ki-67/MIB-index, and recurrence. Univariate and multivariable regression analyses were conducted. RESULTS: A total of 209 meningioma patients were included. Of these, 143 (68 %) were WHO grade I, 61 (29 %) grade II and 5 (2 %) were grade III. Recurrence was reported in 19 (9.1 %) tumors. No hematologic markers were associated with recurrence. In separate multivariable logistic analyses, no biomarkers were associated with perilesional edema or WHO grade. MLR was associated with higher MIB-index (p = 0.018, OR 6.57, 95 % CI 1.37-30.91). CONCLUSION: Most hematologic markers were not associated with meningioma invasiveness, grade, proliferative index, or aggressiveness. Preoperative MLR was associated with high proliferation index in patients undergoing surgery for intracranial meningioma. Higher MLR could be a surrogate for meningioma proliferation and has potential to be used as an adjunct for risk-stratifying meningiomas.

Neurological Examination Frequency and Time-to-Delirium After Traumatic Brain Injury.

BACKGROUND: Frequent neurological examinations in patients with traumatic brain injury (TBI) disrupt sleep-wake cycles and potentially contribute to the development of delirium. OBJECTIVE: To evaluate the risk of delirium among patients with TBI with respect to their neuro-check frequencies. METHODS: A retrospective study of patients presenting with TBI at a single level I trauma center between January 2018 and December 2019. The primary exposure was the frequency of neurological examinations (neuro-checks) assigned at the time of admission. Patients admitted with hourly (Q1) neuro-check frequencies were compared with those who received examinations every 2 (Q2) or 4 (Q4) hours. The primary outcomes were delirium and time-to-delirium. The onset of delirium was defined as the first documented positive Confusion Assessment Method for the Intensive Care Unit score. RESULTS: Of 1552 patients with TBI, 458 (29.5%) patients experienced delirium during their hospital stay. The median time-to-delirium was 1.8 days (IQR: 1.1, 2.9). Kaplan-Meier analysis demonstrated that patients assigned Q1 neuro-checks had the greatest rate of delirium compared with the patients with Q2 and Q4 neuro-checks ( P < .001). Multivariable Cox regression modeling demonstrated that Q2 neuro-checks (hazard ratio: 0.439, 95% CI: 0.33-0.58) and Q4 neuro-checks (hazard ratio: 0.48, 95% CI: 0.34-0.68) were protective against the development of delirium compared with Q1. Other risk factors for developing delirium included pre-existing dementia, tobacco use, lower Glasgow Coma Scale score, higher injury severity score, and certain hemorrhage patterns. CONCLUSION: Patients with more frequent neuro-checks had a higher risk of developing delirium compared with those with less frequent neuro-checks.

Red blood cell distribution width in glioblastoma.

INTRODUCTION: Glioblastoma (GBM) is the most common and deadly adult brain tumor. Red blood cell distribution width (RDW) has been found in non-central nervous system neoplasms to be associated with survival. This study aims to assess the prognostic value of pre-operative RDW and trends in RDW over time during the disease course. METHODS: This single-institution retrospective cohort study identified patients ≥ 18 years old with pathology-proved glioblastoma treated between April 2003-May 2017 from an institutional database. A Cox proportional hazards model was developed using known prognostic clinical variables to predict overall survival time; a second model incorporating continuously valued RDW was then created. The additional prognostic value of RDW was assessed with a joint model F-test. The variation of RDW-CV over time was evaluated with linear mixed model of RDW. A post-hoc exploratory analysis was performed to assess the trend in RDW lab value leading up to time of death. RESULTS: 346 adult GBM patients were identified; complete survival data was available for all patients. The addition of RDW to the multivariable Cox proportional hazards model did not increase prognostic value. There was an upward trend in RDW throughout the post-operative disease course. In a post-hoc analysis, there was an upward trend in RDW leading up to the time of death. CONCLUSION: Although RDW has been prognostic of survival for many inflammatory, prothrombotic, and neoplastic diseases, pre-operative RDW was not associated with overall survival in GBM patients. RDW trended upwards throughout the disease course, suggesting possible systemic inflammatory effects of either glioblastoma or treatment.

Child participation in collision sports and football: what influences parental decisions?

OBJECTIVE: Sport participation promotes health benefits for children. Current media and scientific coverage of sport-related head injury may influence a parent's decision on sports participation. Physicians must understand what influences these decisions to effectively counsel patients and families. This study sought to better understand and quantify the parental decisions to allow/disallow collision sports, including football participation. METHODS: A 31-question survey related to child/parent demographics, sports history, and influences to allow/disallow sport participation was available to parents in the United States through a national volunteer registry, between November 2016 and September 2019. Pearson's chi-squared and Wilcoxon's signed-rank test were used to analyze categorical and continuous variables, respectively. Multivariate logistic regression was performed to identify the most powerful factors associated with the decision. RESULTS: Of the 884 responses, 430 (49%) parents would disallow collision sport participation and 334 (38%) would disallow football. Parents who would allow collision sports more commonly cited child desire, while those parents who would disallow cited safety concern as the greatest influence to generally disallow a sport. Those who would disallow reported doctors (35.1% vs 25.3%; P = 0.002), media (12.8% vs 7.3%; P = 0.006) and other parents (11.2% vs 7.3%; P = 0.045) as influences. A child's age (OR 1.039, 95%CI 1.007-1.073; P = 0.018) was independently associated with their parent responding that they would allow collision sports. Parent educational status showed that those with higher than a bachelor's degree would be less likely to allow football participation (OR 0.635, 95%CI 0.443-0.910; P = 0.013). CONCLUSIONS: Parents incorporate many sources of information into the decision to allow or disallow their child to participate in collision sports. A child's desire to play a sport and child safety are driving factors for parents faced with the decision of whether to allow participation in collision sports. Physician input is more frequently influential to parents than the media, underscoring the responsibility of physicians to engage families on the risks, benefits, and resources available for sport participation.

The survival of reimplanted shunts following externalization: a single-institution cohort study.

OBJECTIVE: The failure-free survival of ventriculoperitoneal shunts (VPSs) following externalization for distal catheter infection or malfunction has not been adequately explored. Conversion to a ventriculoatrial shunt (VAS) may allow earlier reinternalization in lieu of waiting for the peritoneum to be suitable for reimplantation. This option is tempered by historical concerns regarding high rates of VAS failure, and the risks of rare complications are rampant. METHODS: In this retrospective cohort study, all patients undergoing externalization of a VPS at a single institution between 2005 and 2020 were grouped according to the new distal catheter terminus location at the time of reinternalization (VPS vs VAS). The primary outcomes were failure-free shunt survival and duration of shunt externalization. Secondary outcomes included early (< 6 months) shunt failure. RESULTS: Among 36 patients, 43 shunt externalization procedures were performed. Shunts were reinternalized as VPSs in 25 cases and VASs in 18 cases. The median failure-free survival was 1002 (interquartile range [IQR] 161-3449) days for VPSs and 1163 (IQR 360-2927) days for VASs. There was no significant difference in shunt survival according to the new distal catheter terminus (log-rank, p = 0.73). Conversion to a VAS was not associated with shorter duration of shunt externalization (Wilcoxon rank-sum, p = 0.64); the median duration was 7 (IQR 5-11) days for VPSs and 8 (IQR 6-15) days for VASs. No rare complications occurred in the VAS group. CONCLUSIONS: Shunt failure-free survival rates following externalization are similar to published survival rates for nonexternalized shunts. There was no significant difference in survival between reinternalized VPSs and VASs. Although the VAS was not associated with a shortened duration of externalization, this finding is confounded by strong institutional preference for the VPS over the VAS. Early conversion to the VAS may be a viable treatment option in light of reassuring modern VAS survival data.

The Effect of Timing of Surgery in Pituitary Apoplexy on Continuously Valued Visual Acuity.

Background Pituitary apoplexy is often treated urgently, but this is based on studies which assess vision categorically and dichotomizes the time interval between symptom onset and surgery which may introduce bias in measuring an association between the two. Objective This study was aimed to assess for a relationship between continuously valued surgery delay and visual acuity recovery after pituitary apoplexy. Methods In this retrospective study, all patients presenting with symptomatic pituitary apoplexy between 2004 and 2016 were identified from an institutional database. The primary endpoint was visual acuity improvement, measured as the difference in acuity from the pre- to postoperative period, and measured in Logarithm of the Minimal Angle of Resolution (LogMAR) units. Analysis was performed using continuous values of time delay and visual acuity to assess for an underlying association. Results Thirty-two pituitary apoplexy patients were identified. Visual acuity deficits were reported in 81%. The median visual acuity was 0.35 LogMAR (Snellen's fraction 20/40) preoperatively, and 0.1 (20/25) postoperatively ( p < 0.01). The time between symptom onset and surgery was not associated with improvement in visual acuity ( p = 0.46). When the time delay and visual outcome were intentionally dichotomized, patients undergoing surgery within 2 days of symptom onset had 0.21 times the odds of a good visual outcome (95% confidence interval [CI]: 0.04-1.05). Conclusion When assessed as continuously valued measures, the time from symptom onset to surgical intervention and the improvement in visual acuity are not associated, although intentional dichotomization of data produced conflicting results.

Outcomes of Transzygomatic Middle Cranial Fossa Approach for Skull Base Tumors-A Single Institutional Experience.

Objective This study aimed to evaluate surgical outcomes after transzygomatic middle cranial fossa (MCF) (TZ-MCF) approach for tumor control in patients with large skull base lesions involving the MCF and adjacent sites. Setting This study was done at the tertiary skull base center. Design This is a retrospective case series. Main Outcome Measures The main outcome measures were tumor control (recurrence), new-onset cranial neuropathies, facial nerve and audiometric outcomes, cerebrospinal fluid (CSF) leak, and wound complications. Results Sixteen patients were identified with a median age of 45 years (range: 20-72). The mean maximum tumor dimension was 5.49 cm (standard deviation [SD]: 1.2, range: 3.1-7.3) and the mean tumor volume was 28.5 cm 3 (SD: 18.8, range: 2.9-63.8). Ten (62.5%) tumors were left sided. The most common pathology encountered was meningioma ( n = 7) followed by chondrosarcoma ( n = 4). Mean follow-up was 36.3 (SD: 26.9) months. Gross total resection or near total resection was achieved in nine (56.2%) and planned subtotal resection was used in seven (43.7%). Postoperative additional new cranial nerve (CN) deficits included CN V ( n = 1), CN III ( n = 2), CN VI ( n = 1), and CN X ( n = 1). Major neurological morbidity (hemiplegia) was encountered in two patients with resolution. There were no cases of CSF leak, meningitis, hemorrhage, seizures, aphasia, or death. There was no recurrence or regrowth of residual tumor. Facial nerve function was preserved in all but one patient (House-Brackmann grade 2). Conclusion Various skull base tumors involving MCF with extension to adjacent sites can be successfully resected using the TZ-MCF approach in a multidisciplinary fashion. This approach yields optimal exposure and permits excellent tumor control with acceptable CN and neurological morbidity.

Data-Driven Residency Training: A Scoping Review of Educational Interventions for Neurosurgery Residency Programs.

BACKGROUND: Neurosurgery residency programs are tasked with imparting large volumes of both clinical knowledge and technical skill to trainees in limited time. Many investigators have described local practices, which may offer evidence-based interventions in neurosurgical residency education, but this literature has not been systematically reviewed. OBJECTIVE: To perform a scoping review of educational practices in neurosurgery, which are supported by quantitative, peer-reviewed research. METHODS: A scoping review of the literature was performed. PubMed, Embase, and Web of Science databases were queried for articles describing educational interventions for neurosurgery residents, which included a quantitative assessment of the effect on resident performance. RESULTS: From an initial set of 1785 unique articles, 29 studies were ultimately screened and included. Studies were into the following 6 topics: (1) didactics and curricula (n = 13), (2) nontechnical skills (n = 6), (3) wellness and burnout (n = 4), (4) assessment and feedback (n = 2), (5) mentorship and career development (n = 2), and (6) research (n = 2). Individual study results were described. CONCLUSION: Several educational interventions in neurosurgical training are supported by quantitative evidence. Methodological shortcomings are prevalent among studies of education, particularly in the selection of meaningful outcome measures. A summary of evidence-based considerations is provided for current and future program directors.

Statins as a Medical Adjunct in the Surgical Management of Chronic Subdural Hematomas.

BACKGROUND: By stabilizing immature leaky vessel formation in neomembranes, statin drugs have been suggested as a nonsurgical treatment option for chronic subdural hematomas (cSDH). Statin therapy seems to reduce conservatively managed cSDH volume. However, the usefulness of these medications in supplementing surgical treatment is unknown. OBJECTIVE: To investigate the effect of concurrent statin therapy on outcomes after surgical treatment of cSDH. METHODS: A retrospective single-institution cohort study of surgically managed patients with convexity cSDH between 2009 and 2019 was conducted. Patients receiving this diagnosis who underwent surgical decompression were included, and those without follow-up scans were excluded. Demographic, clinical, and radiographic variables were collected. cSDH size was defined as maximum radial thickness in millimeters on axial computed tomography of the head. Multivariable linear regression was performed to identify factors (including statin use) that were associated with preoperative to follow-up cSDH size change. RESULTS: Overall, 111 patients, including 36 patients taking statins on admission, were evaluated. Median time to follow-up postoperative imaging was 30 days (interquartile range, 17-42 days). Patients on statins were older (median, 75 years, range, 68-78.25 years vs. 69 years, range, 59-7 years; P = 0.006) and reported more antiplatelet use (67% vs. 28%; P < 0.001). Median change in follow-up size was 13 mm in both statin and nonstatin groups. Adjusting for other clinical covariates, statin use was associated with greater reduction in cSDH size (CE = -6.72 mm, 95% confidence interval, -13.18 to -0.26 mm; P = 0.042). CONCLUSIONS: Statin use is associated with improved cSDH size postoperatively. Statin drugs might represent a low-cost and low-risk supplement to the surgical management for patients with cSDH.

The value of simplicity: externally validating the Baylor cranial gunshot wound prognosis score.

OBJECTIVE: Gunshot wounds to the head (GSWH) are devastating injuries with a grim prognosis. Several prognostic scores have been created to estimate mortality and functional outcome, including the so-called Baylor score, an uncomplicated scoring method based on bullet trajectory, patient age, and neurological status on admission. This study aimed to validate the Baylor score within a temporally, institutionally, and geographically distinct patient population. METHODS: Data were obtained from the trauma registry at a level I trauma center in the southeastern US. Patients with a GSWH in which dural penetration occurred were identified from data collected between January 1, 2009, and June 30, 2019. Patient demographics, medical history, bullet trajectory, intent of GSWH (e.g., suicide), admission vital signs, Glasgow Coma Scale score, pupillary response, laboratory studies, and imaging reports were collected. The Baylor score was calculated directly by using its clinical components. The ability of the Baylor score to predict mortality and good functional outcome (Glasgow Outcome Scale score 4 or 5) was assessed using the receiver operating characteristic curve and the area under the curve (AUC) as a measure of performance. RESULTS: A total of 297 patients met inclusion criteria (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male). A total of 205 (69.0%) patients died, whereas 69 (23.2%) patients had good functional outcome. Overall, the Baylor score showed excellent discrimination of mortality (AUC = 0.88) and good functional outcome (AUC = 0.90). Baylor scores of 3-5 underestimated mortality. Baylor scores of 0, 1, and 2 underestimated good functional outcome. CONCLUSIONS: The Baylor score is an accurate and easy-to-use prognostic scoring tool that demonstrated relatively stable performance in a distinct cohort between 2009 and 2019. In the current era of trauma management, providers may continue to use the score at the point of admission to guide family counseling and to direct investment of healthcare resources.