Carbon ion radiotherapy for skull base chordomas and chondrosarcomas: a systematic review and meta-analysis of local control, survival, and toxicity outcomes.

BACKGROUND: Carbon ion radiotherapy (CIRT) is an emerging radiation therapy to treat skull base chordomas and chondrosarcomas. To date, its use is limited to a few centers around the world, and there has been no attempt to systematically evaluate survival and toxicity outcomes reported in the literature. Correspondingly, the aim of this study was to qualitatively and quantitatively assess these outcomes. METHODS: A systematic search of seven electronic databases from inception to November 2019 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Outcomes were then pooled by random-effects meta-analyses of proportions. RESULTS: A total of nine studies provided unique metadata for assessment, with six originating from Heidelberg, Germany. The surveyed cohort size was 632 patients, with 389 (62%) chordomas and 243 (38%) chondrosarcomas of the skull base. Across all studies, median cohort age at therapy and female proportion were 46 years and 51% respectively. Estimates of local control incidence at 1-, 5-, and 10-years in chordoma-only studies were 99%, 80%, and 56%, and in chondrosarcoma-only studies were 99%, 89%, and 88%. Estimates of overall survival probability at 1-, 5-, and 10-years in chordoma-only studies were 100%, 94%, and 78%, and in chondrosarcoma-only studies were 99%, 95%, and 79%. The incidence of early and late toxicity (Grade ≥ 3) ranged from 0 to 4% across all study groups. CONCLUSIONS: The emerging use of CIRT to treat skull base chordomas and chondrosarcomas appear promising with regard to tumor control, overall survival, and risk profile of early and late toxicity. The current literature suffers from the fact only a few centers in the world currently employ this technology.

The prognostic significance of CDKN2A homozygous deletion in IDH-mutant lower-grade glioma and glioblastoma: a systematic review of the contemporary literature.

BACKGROUND: The most recent cIMPACT-NOW update highlighted the homozygous deletion of the Cyclin Dependent Kinase Inhibitor 2A (CDKN2A) gene as a clinically important molecular alteration in IDH-mutant glioma. Correspondingly, we systematically reviewed the contemporary literature to affirm the contemporary stance of the literature on the prognostic significance of this alteration in this setting based on the current World Health Organization (WHO) Grade classification. METHODS: A systematic search of seven electronic databases from inception to February 2020 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria to include lower-grade glioma (LGG, WHO Grade II/III) and glioblastoma (GBM, WHO Grade IV) separately. Progression free survival (PFS) and overall survival (OS) from Kaplan-Meier and multivariable analyses were outcomes of interest. RESULTS: Nine institutional studies describing 2193 IDH-mutant gliomas satisfied criteria for evaluation, with 1756 (80%) LGG and 437 (20%) GBM. When reported, the proportion of CDKN2A homozygous deleted gliomas ranged from 9 to 43%, with a median incidence of 22%. For LGG, Kaplan-Meier analyses demonstrated shorter PFS in the presence of CDKN2A homozygous deletion in three studies (median values, 31 versus 91 months), and shorter OS in five studies (median values, 61 versus 154 months). For GBM, Kaplan-Meier analyses demonstrated shorter PFS in the presence of CDKN2A homozygous deletion in two studies (median values, 16 versus 30 months), and shorter OS in four studies (median values, 38 versus 86 months). By multivariable analyses, CDKN2A homozygous deletion was a predictor of significantly shorter PFS and OS in both LGG and GBM across all included studies. CONCLUSIONS: The CDKN2A homozygous deletion is an important prognostic factor for survival outcomes of IDH-mutant glioma patients across multiple histologic WHO grades with specific molecular features likely dependent on IDH-mutant status. Greater understanding of how identifying this deletion can assist in the stratification of management for these tumors to optimize clinical course is required.

Anatomy and white matter connections of the lateral occipital cortex.

PURPOSE: White matter tracts link different regions of the brain, and the known functions of those interconnected regions may offer clues about the roles that white matter tracts play in information relay. The authors of this report discuss the structure and function of the lateral occipital lobe and how the lateral occipital lobe communicates with other regions via white matter tracts. METHODS: The authors used generalized q-sampling imaging and cadaveric brain dissections to uncover the subcortical white matter connections of the lateral occipital lobe. The authors created GQI of ten healthy controls and dissected ten cadaveric brains. RESULTS: The middle longitudinal fasciculus, vertical occipital fasciculus, inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, optic radiations, and a diverse array of U-shaped fibers connect the lateral occipital lobe to itself, parts of the temporal, parietal, and medial occipital cortices. The complex functional processes attributed to the lateral occipital lobe, including object recognition, facial recognition, and motion perception are likely related to the subcortical white matter tracts described within this study. CONCLUSIONS: There was good concordance between the white matter tracts generated using GQI and the white matter tracts that were found after dissection of the cadaveric brains. This article presents the anatomic connections of the lateral occipital lobe and discusses the associated functions.

Left anterior cranial fossa dural arteriovenous fistula ligation using a supra-orbital (eyebrow) craniotomy.

A 67-year-old male presented to the hospital with a left anterior cranial fossa arteriovenous fistula connecting the anterior ethmoidal artery to the cavernous sinus and superior sagittal sinus. After failed embolization, the patient was taken for a supra-orbital (eyebrow) craniotomy for surgical dissection and clipping of the fistula. An intraoperative angiogram confirmed successful fistula ligation. The patient was discharged without complications.The video can be found here: https://youtu.be/79Pk11SEkJg.

Pain Management for Periacetabular Osteotomy: A Systematic Review.

Background: Early post-operative pain control is essential to facilitate rapid recovery after orthopaedic surgery. Despite periacetabular osteotomy (PAO) being the gold standard treatment of prearthritic hip dysplasia, there is limited evidence assessing efficacy of early post-operative pain management strategies. Recent literature has focused on non-opioid supplemental treatments such as nerve blocks or local wound infiltration. The purpose of this systematic review was to assess efficacy of these interventions to reduce pain, facilitate mobilization, reduce length of stay after PAO surgery. Methods: A systematic review was created under the guidance of PRISMA from databases that included PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their creation dates to 12/21/23. These studies were screen based on predetermined inclusion and exclusion criteria. Results: A total of six studies were included in this analysis from independent institutions. Three investigated nerve blocks (fascia iliaca, pericapsular, transversus abdominis), one investigated local wound infiltration with ropivacaine, one investigated high-dose dexamethasone, and the last investigated removal of the epidural catheter on postoperative (POD) 1 compared to POD 2. There were heterogeneous outcomes that were measured from these studies. In general, nerve blocks decreased opioid use, pain, and length of hospital stay. The local wound infiltration decreased pain on POD 3 and 4. Removing the epidural catheter on POD1 compared to POD 2 decreased pain and length of stay. High-dose dexamethasone use decreased opioid use on POD 1, otherwise, there was no difference in pain. Conclusion: In summary, supplemental pain management strategies peri-operatively for PAO surgery can decrease pain, opioid use, and length of hospital stay, though there are few studies assessing these interventions. Limiting opioid use after surgery reduces known negative consequences of the medication and facilitates rapid recovery. Clinical trials are needed that assess efficacy of supplemental pain management strategies after PAO surgery. Level of Evidence: II.

Hip Dysplasia Treated With Periacetabular Osteotomy in Patients Over 40 Years Old: A Systematic Review.

Background: Hip dysplasia is a leading cause of hip osteoarthritis. While periacetabular osteotomy (PAO) is effective for relieving pain and dysfunction caused by hip dysplasia in adolescents and young adults, there is concern that patients over 40 years of age will have an increased risk of persistent dysfunction and need for total hip arthroplasty. Current available evidence for PAO in older adults is limited and there is no systematic review in the literature focusing on this topic. The current systematic review offers insight into the demographics, patient-reported outcome measure (PROM) scores, and hip survivorship from total hip arthroplasty in patients over 40 years older treated for hip dysplasia with PAO. Methods: The review was conducted under the guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Databases that were searched included PubMed, OVID Medline, SCOPUS, Embase, Cochrane Library, and clinicaltrials.gov. Studies were screened based on predetermined inclusion and exclusion criteria. Results: Five studies were included in this systematic review. Enrollment years were 1990-2013. In total, there were 335 hips with mean ages between 43.5-47.2 years. Mean follow up was 4-10.8 years. Most patients that underwent hip preservation had Tonnis osteoarthritis grade 0-1. There was contradicting evidence whether patients >40 years did better or worse compared to <40 years; although, most patients in the >40 years group had good outcomes after PAO. PAO survivorship ranged from 67-100% depending on the study. Complications ranged from 2-36% of cases depending on the study; although, none of these complications had lasting effects. Conclusion: Patients over 40 years old appear to have positive outcomes when treated for hip dysplasia with PAO, though these patients were likely selected for no to minimal osteoarthritis, high functional status, and good health. PAO should be considered for patients with hip dysplasia over 40 years old without hip arthritis, though we recommend very selective indications. Level of Evidence: II.

Prevalence of Radiographic Hip Dysplasia in the General Adult Population: A Systematic Review.

Background: Acetabular dysplasia has a wide range of prevalence reported in the literature. This variation is likely due to differences in the population under investigation and studies focusing on cohorts with hip pain and osteoarthritis. There are reports of radiographic hip dysplasia prevalence for adults without hip pain but there is no systematic review of these studies to document the incidence in the general population. The purpose of this systematic review was to provide a full summary of all studies that report prevalence of hip dysplasia in adults without hip pain. Methods: PRISMA guidelines were utilized as an outline for this systematic review. Articles were pulled from PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their inception dates to 1/7/24. Studies were included if participants were asymptomatic and reported rates of prevalence. Results: Fourteen studies were included in this systematic review. There were 10,998 hips from 5,506 participants included in this analysis. The overall prevalence of radiographic hip dysplasia was 2.3%. Eight studies of 5,930 hips reported the prevalence of hip dysplasia by sex. The prevalence rate in these studies was 3.8% in females and 2.7% in males. Conclusion: Acetabular dysplasia based on radiographic measurements is relatively common in the general adult population. Furthermore, females have a higher prevalence rate when compared to males. It is important to recognize the incidence of hip dysplasia in the asymptomatic adult population as we recommend surgical treatment for patients who present with hip pain and dysplasia. Further studies should investigate the natural history of untreated and treated hip dysplasia. Level of Evidence: III.

Predictive Factors for Intraoperative Determination for the Need of Femoral Osteochondroplasty After Periacetabular Osteotomy for Acetabular Dysplasia.

Background: Determination of need for osteochondroplasty (OCP) during periacetabular osteotomy (PAO) commonly relies on intraoperative assessment of internal rotation at 90° flexion (IRF). Performing an OCP helps decrease the risk of iatrogenic femoroacetabular impingement from PAO reduction. Avoiding impingement helps decrease risks of accelerated secondary osteoarthritis. The literature is limited for factors that predict need for OCPs during PAOs. The purpose of this study was to (1) define the characteristics of patients needing concurrent OCP and provide OCP rate based on IRF and femoral version and (2) identify predictive factors (clinical, radiographic) associated with need for OCP during PAO. As some surgeons determine need for OCP pre-operatively, predictive factors would aid decision making. Methods: This was a prospective cohort of 224 hips (207 patients) who underwent PAO for symptomatic acetabular dysplasia, of which 154 hips (69%) underwent OCP between years 2013 and 2017. Patients underwent OCP if they had restrictions in motion or impingement intra-operatively. Pre-operative factors such as age, sex, BMI, and CT findings were recorded that underwent univariate and multivariable analyses. Multivariable analysis found predictors that were described using odds ratios and 95% confidence intervals. IRF>30° and femoral version 10°-25° were used as the reference groups during categorical analysis. P-values ≤0.05 were considered significant. Results: Alpha angles >55° (OR= 2.20, CI: 1.08-4.52, p= 0.03), IRF≤20° (OR: 9.52, CI: 3.87-23.40, p<0.001), IRF >20°-30° (OR: 2.68, CI: 1.08-6.62, p=0.03), and femoral version <10° (OR: 5.26, CI: 1.09-25.30, p=0.04) were associated with increased odds of OCP. On continuous modeling, decreasing femoral version (OR: 1.07, CI: 1.02-1.12, p=0.002) and IRF (OR: 1.06, CI: 1.03-1.09, p<0.001) were associated with increased chance of OCP. For 5° changes, the chance of OCP increased by 40% (OR: 1.40, CI: 1.13-1.73, p=0.002) and 35% (OR: 1.35, IC: 1.16-1.57, p<0.001), respectively. Conclusion: Awareness of need for OCP may be valuable in peri-operative planning for these patients especially since some surgeons perform this technique arthroscopically before PAO. Factors associated with increased chances of OCP were alpha angles >55°, decreased IRF, and decreased femoral version. More studies in the future would help determine how OCP affects patient outcomes. Level of Evidence: III.

Primary Repair of Posteriorly Located Anterior Skull Base Dural Defects Using Nonpenetrating Titanium Clips in Cranial Trauma.

Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae. Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported. Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation. Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.

Dynamic Occlusion of Distal Ventriculoperitoneal Shunt Catheter after Infusion Port Placement: A New Shunt Malfunction.

Shunt failure requiring reintervention remains a common complication of hydrocephalus treatment. Here, we report a novel cause of mechanical shunt obstruction in an adult patient: position-dependent intermittent occlusion via an infusion port catheter. A 51-year-old woman with a grade II oligodendroglioma presented in a delayed fashion following surgery with a pseudomeningocele. She underwent ventriculoperitoneal shunt placement due to communicating hydrocephalus, resolving her pseudomeningocele. Shortly thereafter, she underwent placement of a subclavian infusion port at an outside institution. Her pseudomeningocele returned. Imaging demonstrated close proximity of her port catheter to the shunt catheter overlying the clavicle. Her shunt was tapped demonstrating a patent ventricular catheter with normal pressure. She underwent shunt exploration after her pseudomeningocele did not respond to valve adjustment. Intraoperative manometry demonstrated head position-dependent distal catheter obstruction. Repeat manometry following distal catheter revision demonstrated normal runoff independent of position. Her pseudomeningocele was resolved on follow-up. To our knowledge, this is the only reported case of intermittent, position-dependent distal catheter obstruction. Shunted patients with concern for malfunction following subclavian infusion port placement should be evaluated for possible dynamic obstruction of their distal catheter when the two catheters are in close proximity along the clavicle.

Comparative Analysis of Survival Outcomes and Prognostic Factors of Supratentorial versus Cerebellar Glioblastoma in the Elderly: Does Location Really Matter?

BACKGROUND: Cerebellar glioblastomas (cGBMs) are rare tumors that are uncommon in the elderly. In this study, we compare survival outcomes and identify prognostic factors of cGBM compared with the supratentorial (stGBM) counterpart in the elderly. METHODS: Data from the SEER 18 registries were used to identify patients with a glioblastoma (GBM) diagnosis between 2000 and 2016. The log-rank method and a multivariable Cox proportional hazards regression model were used for analysis. RESULTS: Among 110 elderly patients with cGBM, the median age was 74 years (interquartile range [IQR], 69-79 years), 39% were female and 83% were white. Of these patients, 32% underwent gross total resection, 73% radiotherapy, and 39% chemotherapy. Multivariable analysis of the unmatched and matched cohort showed that tumor location was not associated with survival; in the unmatched cohort, insurance status (hazard ratio [HR], 0.11; IQR, 0.02-0.49; P = 0.004), gross total resection (HR, 0.53; IQR, 0.30-0.91; P = 0.022), and radiotherapy (HR, 0.33; IQR, 0.18-0.61; P < 0.0001) were associated with better survival. Patients with cGBM and stGBM undergoing radiotherapy (7 months vs. 2 months; P < 0.001) and chemotherapy (10 months vs. 3 months; P < 0.0001) had improved survival. Long-term mortality was lower for cGBM in the elderly at 24 months compared with the stGBM cohort (P = 0.007). CONCLUSIONS: In our study, elderly patients with cGBM and stGBM have similar outcomes in overall survival, and those undergoing maximal resection with adjuvant therapies, independent of tumor location, have improved outcomes. Thus, aggressive treatment should be encouraged for cGBM in geriatric patients to confer the same survival benefits seen in stGBM. Single-institutional and multi-institutional studies to identify patient-level prognostic factors are warranted to triage the best surgical candidates.

Flat-Detector CT to Quantify Response to Intra-Arterial Spasmolytic Therapy for Cerebral Vasospasm.

BACKGROUND AND PURPOSE: Cerebral vasospasm in the setting of subarachnoid hemorrhage causes morbidity and mortality due to delayed cerebral ischemia and permanent neurological deficits. Vasospasm treatment includes intra-arterial injection of a spasmolytic during cerebral angiography. To evaluate effectiveness, neurointerventionalists subjectively examine a posttreatment cerebral angiogram to determine change in vessel diameter or increase in microvascular perfusion. Flat-detector computed tomography (FDCT) scanner has the ability to quantitatively measure cerebral blood volume (CBV) within the parenchyma and detect a quantitative change following treatment. METHODS: This is a prospective study at a single institution between October 5, 2017 and June 3, 2019 that examines CBV studies from the Artis Q biplane (Siemens). Regions of interest were made in various territories to measure the CBV within the parenchyma before and after treatment with the spasmolytic verapamil. All instances of vasospasm involved vasculature within the left middle cerebral artery or internal carotid artery. The Wilcoxon signed-rank test was used to determine significance before and after treatment. RESULTS: Our cohort consists of 6 patients who underwent Digital Subtraction Angiography (DSA) and FDCT scans for cerebral vasospasm within the left hemisphere. After intra-arterial injection of 20 mg of verapamil, average increases in blood volume were 59%, 22%, and 24% for the temporal, frontal, and parietal lobes, respectively. P-values associated were .03. We also observed decrease in the mean arterial blood pressure and transcranial Doppler values after treatment. CONCLUSION: In conclusion, FDCT could measure the effectiveness of a change in CBV from infusion of verapamil in the setting of cerebral vasospasm. The authors believe quantifying the change allows for reassurance of improvement of cerebral vasospasm.

Solitary osteochondroma of the cervical spine presenting with quadriparesis and hand contracture.

BACKGROUND: Spinal osteochondromas are rare, benign tumors arising from the cartilaginous elements of the spine that may appear as solitary lesions versus multiple lesions in patients with hereditary multiple exostoses. Here, we present a 15-year-old female with a solitary C3-C4 osteochondroma who presented with a progressive quadriparesis and hand contracture successfully managed with a laminectomy/posterior spinal fusion. CASE DESCRIPTION: A 15-year-old female presented with a 3-month history of progressive quadriparesis and hand contracture secondary to a magnetic resonance (MR) documented C3-C4 cervical spine osteochondroma. The MR imaging revealed a solitary osseous extramedullary outgrowth arising from the left laminar cortex of the C-3 vertebral body extending to C-4. Due to the marked resultant canal stenosis, the patient underwent a cervical laminectomy of C3- C4 with posterior spinal fusion. Gross total resection was achieved, and the pathology confirmed an osteochondroma. The patient's myelopathy resolved, and 2 years later, she demonstrated no residual deficits or tumor recurrence. CONCLUSION: Here, we report the successful management of a 15-year-old female with a C3-C4 osteochondroma and progressive quadriparesis through cervical laminectomy/fusion.

Embolization and Open Decompression of a Giant Aneurysm Involving the P2 Segment of the Posterior Cerebral Artery.

A 5-year-old girl was brought to the clinic because of chronic intermittent left-sided headaches. The patient underwent computed tomographic angiography, which demonstrated a giant aneurysm that involved the P2 segment of the left posterior cerebral artery. Before treatment proceeded, consent was obtained from the patient's legal guardian. A trapping-evacuation technique was used for proximal control and decompression so that a clip could be placed on the proximal inflow artery of the aneurysm. First, embolization was performed for aneurysm trapping and for sacrifice of the parent vessel. Two days later, the patient was taken to the operating room for open surgical decompression, clipping, and reconstruction. Heparin was administered during the embolization stage of the operation. The patient did well postoperatively and was discharged home. The 3-month follow-up evaluation demonstrated a right superior homonymous quadrantanopia and no other neurologic deficits. The patient's clinical course is summarized in Video 1.

Presenting NIHSS predicts 90-day functional outcome after mechanical thrombectomy for basilar artery occlusion: A systematic review and meta-analysis.

The prediction of outcome after mechanical thrombectomy (MT) of basilar artery occlusion (BAO) remains an area of investigation. The objective of this study was to evaluate the prognostic role of presenting National Institute Health of Stroke Scale (NIHSS) scores in predicting favorable 90-day functional outcome. A survey of 7 electronic databases from inception to May 2020 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate odds ratios (ORs) for favorable 90-day function outcome (modified Rankin Score 0-2) were extracted and pooled by meta-analysis of proportions with random effects modeling. A total of 10 individual studies satisfied criteria for selection and described a total of 941 BAO patients managed by MT. Analysis revealed 590 (63%) males with a mean age of 66.6 years. The median presenting NIHSS was 19, and 316 (34%) patients were reported to have a favorable functional status 90-days after treatment. Lower presenting NIHSS scores independently and significantly predicted favorable 90-day functional outcome in BAO patients with a pooled OR of 0.89 (95% CI, 0.87-0.92; I2 = 18%; P-heterogeneity = 0.28). Meta-regression did not detect any clinical parameter that influenced this trend direction or its significance, and bias assessments were unremarkable. We confirm in this study via a consensus within the literature that the presenting NIHSS score predicts 90-day functional outcome in BAO patients treated by MT. Further, its standardized use allows more meaningful comparisons between interventions and anatomical locations.

Cryptococcal Choroid Plexitis and Non-Communicating Hydrocephalus.

Cryptococcus neoformans is a fungus that commonly invades the central nervous system. While the choroid plexus, the site of the blood-cerebrospinal fluid barrier, serves as one potential entry point for the pathogen, disease involvement of the choroid plexus itself remains a very rare manifestation of Cryptococcus infection. In cases in which choroid plexus involvement blocks cerebrospinal fluid flow, obstructive hydrocephalus may occur. Here we report the case of a 63-year-old woman who presented with choroid plexitis causing obstructive hydrocephalus at the foramen of Monro. Endoscopic biopsy confirmed Cryptococcus neoformans, and the patient was successfully treated with amphotericin, flucytosine, and fluconazole. With proper recognition and treatment of this pathology, patients can fully recover from this condition.

Laser Interstitial Thermal Therapy for Metastatic Melanoma After Failed Radiation Therapy: A Case Series.

BACKGROUND: Laser interstitial thermal therapy (LITT) is a growing technology to treat a variety of brain lesions. It offers an alternative to treatment options, such as open craniotomy and stereotactic radiosurgery. OBJECTIVE: To analyze our experience using LITT for metastatic melanoma. METHODS: This is a retrospective chart review of the patients from our institution. Our case series involves 5 patients who had previously failed radiation treatment. RESULTS: Our patients have low complication rates and short hospital stays. Both are considerably lower when compared to the literature for metastatic melanoma. CONCLUSION: LITT is a safe therapy, with few complications and short hospital stays.

Predicting Clinical Outcome After Mechanical Thrombectomy: The GADIS (Gender, Age, Diabetes Mellitus History, Infarct Volume, and Current Smoker [corrected]) Score.

OBJECTIVE: To investigate predictive factors and develop an outcome assessment tool to determine clinical outcome after endovascular mechanical thrombectomy (EMT) in patients presenting with large vessel occlusion (LVO). METHODS: A retrospective analysis was carried out of a prospective cohort of patients presenting with LVO who underwent EMT after adoption of an expanded time window of ≤24 hours. Final cerebral infarction volume (CIV) after EMT was estimated using magnetic resonance imaging segmentation software. Stepwise linear regression models were used to identify factors that determined clinical outcome and to develop a predictive scale. RESULTS: Ninety patients underwent EMT over 19 months (68 within 6 hours and 22 between 6 and 24 hours). Clinical outcome determined using modified Rankin Scale (mRS) score at discharge and 3 months was no different among these subcohorts. A threshold of 16.99 mL of CIV, using the Youden index, resulted in a sensitivity of 90.5% and specificity of 58.1% for predicting mRS score of 0-2. A regression model identified gender, age, diabetes mellitus status, CIV, and smoking status as outcome determinants, which were used to develop the GADIS (Gender, Age, Diabetes Mellitus History, Infarct Volume, and Sex) scoring system to predict good clinical outcome. Using the GADIS score, <6 predicted mRS score 0-2 at discharge with a sensitivity of 83.3% and specificity of 80.6%. CONCLUSIONS: The GADIS score for patients with LVO-related acute ischemic stroke includes CIV after EMT and helps in early short-term prognostication. It is not intended to predict preintervention patient selection or outcome prediction.

Surgical Treatment of Tethered Cord Syndrome in Adults: A Systematic Review and Meta-Analysis.

OBJECTIVE: In the healthy spine, the spinal cord moves unimpeded with spinal fluid pulsation in the rostral and caudal directions. When a portion of the spinal cord becomes attached to lesions within the spinal column, excess strain can cause signs and symptoms such as pain, motor deficits, sensory deficits, bladder dysfunction, and bowel dysfunction. This condition is termed tethered cord syndrome. There are no clear guidelines for offering surgical intervention, although there is a general consensus that worsening signs and symptoms increase the likelihood that patients will need surgery. METHODS: In this article, we conduct a systematic review and meta-analysis for all available literature within the Ovid (MEDLINE), PubMed, and Google Scholar databases to evaluate common symptoms among patients with tethered cord and to examine how surgery affects symptoms. RESULTS: Within the cohort of 730 patients, 708 (97%) were treated surgically by a detethering procedure. The most common preoperative sign or symptom was pain (81%), followed by motor deficits (63%), sensory deficits (61%), bladder dysfunction (56%), and bowel dysfunction (15%). One percent of patients had no deficit or symptom. Pain was the symptom that was most responsive to surgery, with 81% of patients reporting that their pain improved after detethering. CONCLUSIONS: Tethered cord syndrome should be included in the differential diagnosis in patients presenting with back or leg pain, somatosensory symptoms of the lower extremities, muscular weakness, urodynamic dysfunction, or bowel dysfunction. After a definitive diagnosis is made, patients should be counseled about surgical detethering as an option.

Effect of surgery and chemotherapy on long-term survival in infants with congenital glioblastoma: an integrated survival analysis.

OBJECTIVE: Glioblastoma (GBM) during infancy is rare, and the clinical outcomes of congenital GBM are not well understood. Correspondingly, the aim of this study was to present a long-term survivor case from the authors' institution, and establish an integrated cohort of cases across the published literature to better understand the clinical course of this disease in this setting. METHODS: The authors report the outcomes of an institutional case of congenital GBM diagnosed within the first 3 months of life, and performed a comprehensive literature search for published cases from 2000 onward for an integrated survival analysis. All cases were integrated into 1 cohort, and Kaplan-Meier estimations, Fisher's exact test, and logistic regression were used to interrogate the data. RESULTS: The integrated cohort of 40 congenital GBM cases consisted of 23 (58%) females and 17 (42%) males born at a median gestational age of 38 weeks (range 22-40 weeks). Estimates of overall survival (OS) at 1 month was 67%, at 1 year it was 59%, and at 10 years it was 45%, with statistically superior outcomes for subgroups in which patients survived to be treated by resection and chemotherapy. In the overall cohort, multivariable analysis confirmed resection (p < 0.01) and chemotherapy (p < 0.01) as independent predictors of superior OS. Gestational age > 38 weeks (p < 0.01), Apgar scores ≥ 7 at 5 minutes (p < 0.01), absence of prenatal hydrocephalus (p < 0.01), and vaginal delivery (p < 0.01) were associated with greater odds of surgical diagnosis versus autopsy diagnosis. CONCLUSIONS: Congenital GBM can deviate from the expected poor prognosis of adult GBM in terms of OS. Both resection and chemotherapy confer statistically superior prognostic advantages in those patients who survive within the immediate postnatal period, and should be first-line considerations in the initial management of this rare disease.