Radiomic signatures of meningiomas using the Ki-67 proliferation index as a prognostic marker of clinical outcomes.

OBJECTIVE: The clinical behavior of meningiomas is not entirely captured by its designated WHO grade, therefore other factors must be elucidated that portend increased tumor aggressiveness and associated risk of recurrence. In this study, the authors identify multiparametric MRI radiomic signatures of meningiomas using Ki-67 as a prognostic marker of clinical outcomes independent of WHO grade. METHODS: A retrospective analysis was conducted of all resected meningiomas between 2012 and 2018. Preoperative MR images were used for high-throughput radiomic feature extraction and subsequently used to develop a machine learning algorithm to stratify meningiomas based on Ki-67 indices < 5% and ≥ 5%, independent of WHO grade. Progression-free survival (PFS) was assessed based on machine learning prediction of Ki-67 strata and compared with outcomes based on histopathological Ki-67. RESULTS: Three hundred forty-three meningiomas were included: 291 with WHO grade I, 43 with grade II, and 9 with grade III. The overall rate of recurrence was 19.8% (15.1% in grade I, 44.2% in grade II, and 77.8% in grade III) over a median follow-up of 28.5 months. Grade II and III tumors had higher Ki-67 indices than grade I tumors, albeit tumor and peritumoral edema volumes had considerable variation independent of meningioma WHO grade. Forty-six high-performing radiomic features (1 morphological, 7 intensity-based, and 38 textural) were identified and used to build a support vector machine model to stratify tumors based on a Ki-67 cutoff of 5%, with resultant areas under the curve of 0.83 (95% CI 0.78-0.89) and 0.84 (95% CI 0.75-0.94) achieved for the discovery (n = 257) and validation (n = 86) data sets, respectively. Comparison of histopathological Ki-67 versus machine learning-predicted Ki-67 showed excellent performance (overall accuracy > 80%), with classification of grade I meningiomas exhibiting the greatest accuracy. Prediction of Ki-67 by machine learning classifier revealed shorter PFS for meningiomas with Ki-67 indices ≥ 5% compared with tumors with Ki-67 < 5% (p < 0.0001, log-rank test), which corroborates divergent patient outcomes observed using histopathological Ki-67. CONCLUSIONS: The Ki-67 proliferation index may serve as a surrogate marker of increased meningioma aggressiveness independent of WHO grade. Machine learning using radiomic feature analysis may be used for the preoperative prediction of meningioma Ki-67, which provides enhanced analytical insights to help improve diagnostic classification and guide patient-specific treatment strategies.

Predictors of recurrence after surgical resection of parafalcine and parasagittal meningiomas.

PURPOSE: Owing to their vicinity near the superior sagittal sinus, parasagittal and parafalcine meningiomas are challenging tumors to surgically resect. In this study, we investigate key factors that portend increased risk of recurrence after surgery. METHODS: This is a retrospective study of patients who underwent resection of parasagittal and parafalcine meningiomas at our institution between 2012 and 2018. Relevant clinical, radiographic, and histopathological variables were selected for analysis as predictors of tumor recurrence. RESULTS: A total of 110 consecutive subjects (mean age: 59.4 ± 15.2 years, 67.3% female) with 74 parasagittal and 36 parafalcine meningiomas (92 WHO grade 1, 18 WHO grade 2/3), are included in the study. A total of 37 patients (33.6%) exhibited recurrence with median follow-up of 42 months (IQR: 10-71). In the overall cohort, parasagittal meningiomas exhibited shorter progression-free survival compared to parafalcine meningiomas (Kaplan-Meier log-rank p = 0.045). On univariate analysis, predictors of recurrence include WHO grade 2/3 vs. grade 1 tumors (p < 0.001), higher Ki-67 indices (p < 0.001), partial (p = 0.04) or complete sinus invasion (p < 0.001), and subtotal resection (p < 0.001). Multivariable Cox regression analysis revealed high-grade meningiomas (HR: 3.62, 95% CI: 1.60-8.22; p = 0.002), complete sinus invasion (HR: 3.00, 95% CI: 1.16-7.79; p = 0.024), and subtotal resection (HR: 3.10, 95% CI: 1.38-6.96; p = 0.006) as independent factors that portend shorter time to recurrence. CONCLUSION: This study identifies several pertinent factors that confer increased risk of recurrence after resection of parasagittal and parafalcine meningiomas, which can be used to devise appropriate surgical strategy to achieve improved patient outcomes.

A Review of Endoscopic Spine Surgery: Decompression for Radiculopathy.

PURPOSE OF REVIEW: With this manuscript the authors sought to write a succinct review of the origins, as well as the latest advancements in endoscopic spine surgery to serve as a reference frame for physicians looking to learn this approach. RECENT FINDINGS: At its infancy, the indications for posterolateral and transforaminal endoscopic decompression remained narrow, which prevented the procedure from gaining rapid traction during those days. However, more recently the tides have turned and an increasing number of surgeons are starting to adopt this technique given all its advantages. With the advent of higher quality camera systems and instruments, indications to use a minimally invasive option have gotten significantly broader. The most basic indication for the use of this technology is a soft disc herniation causing compromise of a neural structure that has failed to be managed successfully with non-surgical therapies. The use of endoscopic techniques provides significant advantages to patient outcomes and patient recovery. Endoscopic procedures should not be used as a blanket approach to nerve root decompression, as they certainly have limitations. Most contraindications to this procedure are relative and serve mostly as points to consider when selecting the methods to address neural compression. As these techniques become more widely accepted, we expect its reach and indications to continue to broaden and diversify. The full integration of navigation technologies will likely leapfrog this procedure into the mainstream use.

Neurosurgical Evaluation for Patients with Chronic Lower Back Pain.

PURPOSE OF REVIEW: Chronic low back pain (CLBP) is a major cause of disability in the USA, and it affects approximately 1 in 4 Americans. CLBP patients are commonly referred to or seek out neurosurgical evaluations and opinions for treatment and management. RECENT FINDINGS: Literature shows that only a minority of patients with CLBP may benefit from a surgical procedure. These patients that present to clinic often have been ailing for a considerable amount of time and are eager for effective treatment to alleviate pain. However, determining if a patient with CLBP is a surgical candidate is predicated upon having no success of pain relief with non-operative management. Patients with CLBP require thorough and adequate imaging, clinical exam, and diagnostic evaluation. When adequate non-operative management was provided, and proven fruitless, the patient may be considered an operative candidate. In this manuscript, a framework is presented for workup and evaluation of patients with CLBP.

Coherent Timescales and Mechanical Structure of Multicellular Aggregates.

Multicellular aggregates are an excellent model system to explore the role of tissue biomechanics in specifying multicellular reorganization during embryonic developments and malignant invasion. Tissue-like spheroids, when subjected to a compressive force, are known to exhibit liquid-like behaviors at long timescales (hours), largely because of cell rearrangements that serve to effectively dissipate the applied stress. At short timescales (seconds to minutes), before cell rearrangement, the mechanical behavior is strikingly different. The current work uses shape relaxation to investigate the structural characteristics of aggregates and discovers two coherent timescales: one on the order of seconds, the other tens of seconds. These timescales are universal, conserved across a variety of tested species, and persist despite great differences in other properties such as tissue surface tension and adhesion. A precise mathematical theory is used to correlate the timescales with mechanical properties and reveals that aggregates have a relatively strong envelope and an unusually "soft" interior (weak bulk elastic modulus). This characteristic is peculiar, considering that both layers consist of identical units (cells), but is consistent with the fact that this structure can engender both structural integrity and the flexibility required for remodeling. In addition, tissue surface tension, elastic modulus, and viscosity are proportional to each other. Considering that these tissue-level properties intrinsically derive from cellular-level properties, the proportionalities imply precise coregulation of the latter and in particular of the tension on the cell-medium and cell-cell interfaces.

Dexamethasone-Mediated Upregulation of Calreticulin Inhibits Primary Human Glioblastoma Dispersal Ex Vivo.

Dispersal of Glioblastoma (GBM) renders localized therapy ineffective and is a major cause of recurrence. Previous studies have demonstrated that Dexamethasone (Dex), a drug currently used to treat brain tumor-related edema, can also significantly reduce dispersal of human primary GBM cells from neurospheres. It does so by triggering α5 integrin activity, leading to restoration of fibronectin matrix assembly (FNMA), increased neurosphere cohesion, and reduction of neurosphere dispersal velocity (DV). How Dex specifically activates α5 integrin in these GBM lines is unknown. Several chaperone proteins are known to activate integrins, including calreticulin (CALR). We explore the role of CALR as a potential mediator of Dex-dependent induction of α5 integrin activity in primary human GBM cells. We use CALR knock-down and knock-in strategies to explore the effects on FNMA, aggregate compaction, and dispersal velocity in vitro, as well as dispersal ex vivo on extirpated mouse retina and brain slices. We show that Dex increases CALR expression and that siRNA knockdown suppresses Dex-mediated FNMA. Overexpression of CALR in GBM cells activates FNMA, increases compaction, and decreases DV in vitro and on explants of mouse retina and brain slices. Our results define a novel interaction between Dex, CALR, and FNMA as inhibitors of GBM dispersal.

Inhibition of glioblastoma dispersal by the MEK inhibitor PD0325901.

BACKGROUND: Dispersal of glioblastoma (GBM) cells leads to recurrence and poor prognosis. Accordingly, molecular pathways involved in dispersal are potential therapeutic targets. The mitogen activated protein kinase/extracellular signal regulated kinase (MAPK/ERK) pathway is commonly dysregulated in GBM, and targeting this pathway with MEK inhibitors has proven effective in controlling tumor growth. Since this pathway also regulates ECM remodeling and actin organization - processes crucial to cell adhesion, substrate attachment, and cell motility - the aim of this study was to determine whether inhibiting this pathway could also impede dispersal. METHODS: A variety of methods were used to quantify the effects of the MEK inhibitor, PD0325901, on potential regulators of dispersal. Cohesion, stiffness and viscosity were quantified using a method based on ellipsoid relaxation after removal of a deforming external force. Attachment strength, cell motility, spheroid dispersal velocity, and 3D growth rate were quantified using previously described methods. RESULTS: We show that PD0325901 significantly increases aggregate cohesion, stiffness, and viscosity but only when tumor cells have access to high concentrations of fibronectin. Treatment also results in reorganization of actin from cortical into stress fibers, in both 2D and 3D culture. Moreover, drug treatment localized pFAK at sites of cell-substratum adhesion. Collectively, these changes resulted in increased strength of substrate attachment and decreased motility, a decrease in aggregate dispersal velocity, and in a marked decrease in growth rate of both 2D and 3D cultures. CONCLUSIONS: Inhibition of the MAPK/ERK pathway by PD0325901 may be an effective therapy for reducing dispersal and growth of GBM cells.

Introducing a novel hybrid educational boot camp to augment medical student training in neurosurgery.

OBJECTIVE: Neurosurgery subinternships are a critical portion of the medical student application to neurosurgery residency programs, allowing programs to assess the student's clinical knowledge, interpersonal skills, work ethic, and character. Despite how critical these auditions are, many students have a poor understanding of expectations prior to beginning these subinternships. Thomas Jefferson University hosted a combined in-person and virtual boot camp session open to all medical students interested in neurosurgery. The authors sought to determine the effectiveness of this inaugural course. METHODS: A total of 304 registered participants were sent a survey assessing their attitudes toward neurosurgery subinternships, beliefs about their abilities, and their comfort with various neurosurgical skills. All participants were sent a postsession survey composed of the same questions. The mean scores for responses to pre- and postsession survey questions were recorded based on graduating year and by medical school type (US allopathic [US MD], US osteopathic [US DO], or foreign degree/international medical graduate [IMG]). Differences in means between pre- and postsession survey responses were analyzed using the Student t-test, and statistical significance was set at p < 0.05. RESULTS: A total of 112 presession surveys and 64 postsession surveys were completed, yielding a presession survey response rate of 36.8% and a postsession survey response rate of 21.1%. Seventy-five percent of the postsession survey respondents attended virtually, and 25% were in-person. US MD, US DO, and IMG attendees demonstrated a significantly increased understanding of the expectations of a neurosurgery subintern (p < 0.001). All students had significantly increased confidence in their ability to succeed as subinterns (US MD students and IMGs p < 0.001, US DO students p < 0.05). Regarding procedural confidence, US MD students had increased confidence in craniotomies and cranial plating (p < 0.001). When comparing responses by graduation year, students in the classes of 2024 and 2025 (rising 4th-year and rising 3rd-year medical students, respectively) demonstrated significantly increased understanding of expectations and confidence in their ability to succeed (< 0.001). Seventy-five percent of our postsession survey respondents attended virtually, and 25% were in-person. The in-person cohort had greater improvements in comfort with procedures such as craniotomies, cranial plating, and extraventricular drain placement (in-person vs Zoom mean differences: craniotomies and cranial plating, -2.29, extraventricular drain placement, -2.31) (p < 0.05). CONCLUSIONS: The boot camp successfully delineated the expectations of neurosurgery subinterns and enhanced the attendees' confidence in their abilities. The authors concluded that a hybrid virtual and in-person format is beneficial and feasible in increasing accessibility to information about neurosurgery subinternships.

Early prognostication of overall survival for pediatric diffuse midline gliomas using MRI radiomics and machine learning: a two-center study.

Background: Diffuse midline gliomas (DMG) are aggressive pediatric brain tumors that are diagnosed and monitored through MRI. We developed an automatic pipeline to segment subregions of DMG and select radiomic features that predict patient overall survival (OS). Methods: We acquired diagnostic and post-radiation therapy (RT) multisequence MRI (T1, T1ce, T2, T2 FLAIR) and manual segmentations from two centers of 53 (internal cohort) and 16 (external cohort) DMG patients. We pretrained a deep learning model on a public adult brain tumor dataset, and finetuned it to automatically segment tumor core (TC) and whole tumor (WT) volumes. PyRadiomics and sequential feature selection were used for feature extraction and selection based on the segmented volumes. Two machine learning models were trained on our internal cohort to predict patient 1-year survival from diagnosis. One model used only diagnostic tumor features and the other used both diagnostic and post-RT features. Results: For segmentation, Dice score (mean [median]±SD) was 0.91 (0.94)±0.12 and 0.74 (0.83)±0.32 for TC, and 0.88 (0.91)±0.07 and 0.86 (0.89)±0.06 for WT for internal and external cohorts, respectively. For OS prediction, accuracy was 77% and 81% at time of diagnosis, and 85% and 78% post-RT for internal and external cohorts, respectively. Homogeneous WT intensity in baseline T2 FLAIR and larger post-RT TC/WT volume ratio indicate shorter OS. Conclusions: Machine learning analysis of MRI radiomics has potential to accurately and non-invasively predict which pediatric patients with DMG will survive less than one year from the time of diagnosis to provide patient stratification and guide therapy.

Subependymal giant cell astrocytoma in the absence of tuberous sclerosis: illustrative case.

BACKGROUND: Subependymal giant cell astrocytoma (SEGA) is a benign intraventricular tumor classically arising near the Foramen of Monro. SEGAs almost always present as a component of tuberous sclerosis complex (TSC), an autosomal dominant disorder characterized by lesions in multiple organs. OBSERVATIONS: A 22-year-old female with no past medical history presented with new-onset right-eye pressure, floaters in the right visual field, and pulsatile tinnitus. Imaging revealed an avidly enhancing mass abutting the right Foramen of Monro, causing obstructive hydrocephalus. Following resection, histopathological analysis identified the lesion as a SEGA. However, on further workup, the patient was found to have no genetic or clinical findings of TSC, which exemplifies a rare case of SEGA in the absence of a TSC diagnosis. LESSONS: It is essential for physicians to be aware of the possibility of SEGA in the absence of other characteristics of TSC, which has many implications for a patient's clinical course. The authors present the seventh case of SEGA without genetic or clinical features of TSC described in the literature.

Radio-pathomic approaches in pediatric neuro-oncology: Opportunities and challenges.

With medical software platforms moving to cloud environments with scalable storage and computing, the translation of predictive artificial intelligence (AI) models to aid in clinical decision-making and facilitate personalized medicine for cancer patients is becoming a reality. Medical imaging, namely radiologic and histologic images, has immense analytical potential in neuro-oncology, and models utilizing integrated radiomic and pathomic data may yield a synergistic effect and provide a new modality for precision medicine. At the same time, the ability to harness multi-modal data is met with challenges in aggregating data across medical departments and institutions, as well as significant complexity in modeling the phenotypic and genotypic heterogeneity of pediatric brain tumors. In this paper, we review recent pathomic and integrated pathomic, radiomic, and genomic studies with clinical applications. We discuss current challenges limiting translational research on pediatric brain tumors and outline technical and analytical solutions. Overall, we propose that to empower the potential residing in radio-pathomics, systemic changes in cross-discipline data management and end-to-end software platforms to handle multi-modal data sets are needed, in addition to embracing modern AI-powered approaches. These changes can improve the performance of predictive models, and ultimately the ability to advance brain cancer treatments and patient outcomes through the development of such models.

Clinical Outcomes with and without Adherence to Evidence-Based Medicine Guidelines for Lumbar Degenerative Spondylolisthesis Fusion Patients.

INTRODUCTION: Degenerative lumbar spondylolisthesis (DS) patients are treated with instrumented fusion, following EBM guidelines, and typically have excellent clinical outcomes. However, not all lumbar fusion procedures adhere to EBM guidelines, typically due to a lack of prospective data. OBJECTIVE: This retrospective study compared outcomes of DS lumbar fusion patients treated according to EBM guidelines (EBM concordant) to lumbar fused patients with procedures that did not have clear EBM literature that supported this treatment, the goal being to examine the value of present EBM to guide clinical care. METHODS: A total of 125 DS patients were considered EBM concordant, while 21 patients were EBM discordant. Pre- and postsurgical ODI scores were collected. Clinical outcomes were stratified into substantial clinical benefit (SCB ΔODI >10 points), minimal clinical importance benefit (MCID ΔODI ≥ 5 points), no MCID (ΔODI < 5 points), and a group that showed no change or worsening ODI. Fisher's exact and χ2 tests for categorical variables, Student's t-test for continuous variables, and descriptive statistics were used. Statistical tests were computed at the 95% level of confidence. RESULTS: Analysis of 125 degenerative spondylolisthesis patients was performed comparing preoperative and postoperative (6 months) ODI scores. ODI improved by 8 points in the EBM concordant group vs. 2.1 points in the EBM discordant group (p = 0.002). Compliance with EBM guidelines was associated with an odds ratio (OR) of 2.93 for achieving MCID ([CI]: 1.12-7.58, p = 0.027). CONCLUSIONS: Patients whose lumbar fusions met EBM criteria had better self-reported outcomes at six months than those who did not meet the requirements. A greater knowledge set is needed to help further support EBM-guided patient care.

Increased Surgeon-specific Experience and Volume is Correlated With Improved Clinical Outcomes in Lumbar Fusion Patients.

STUDY DESIGN: The present study design was that of a single center, retrospective cohort study to evaluate the influence of surgeon-specific factors on patient functional outcomes at 6 months following lumbar fusion. Retrospective review of a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis identified the present study population. OBJECTIVE: This study seeks to evaluate surgeon-specific variable effects on patient-reported outcomes such as Oswestry Disability Index (ODI) and the effect of North American Spine Society (NASS) concordance on outcomes in the setting of variable surgeon characteristics. SUMMARY OF BACKGROUND DATA: Lumbar fusion is one of the fastest growing procedures performed in the United States. Although the impact of surgeon-specific factors on patient-reported outcomes has been contested, studies examining these effects are limited. METHODS: This is a single center, retrospective cohort study analyzing a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis by 1 of 5 neurosurgery fellowship trained spine surgeons. The primary outcome was improvement of ODI at 6 months postoperative follow-up compared with preoperative ODI. RESULTS: A total of 307 patients were identified for analysis. Overall, 62% of the study population achieved minimum clinically important difference (MCID) in ODI score at 6 months. Years in practice and volume of lumbar fusions were statistically significant independent predictors of MCID ODI on multivariable logistic regression ( P =0.0340 and P =0.0343, respectively). Concordance with evidence-based criteria conferred a 3.16 (95% CI: 1.03, 9.65) times greater odds of achieving MCID. CONCLUSION: This study demonstrates that traditional surgeon-specific variables predicting surgical morbidity such as experience and procedural volume are also predictors of achieving MCID 6 months postoperatively from lumbar fusion. Independent of surgeon factors, however, adhering to evidence-based guidelines can lead to improved outcomes.

Lumbar Synovial Cysts-Should You Fuse or Not?

BACKGROUND: Spinal synovial cysts are lesions that most commonly occur in the lumbar region. The need for an instrumented spinal fusion in addition to lumbar decompression with removal of the synovial cyst is unknown. OBJECTIVE: To test the hypothesis that select patients who underwent decompression with instrumented fusion for lumbar synovial cysts would be less likely to have subsequent surgery (SS) in a 2-year period than patients treated with laminectomy alone. METHODS: This retrospective cohort study was performed using IBM MarketScan Commercial Claims and Encounters Database. Patients who had a lumbar synovial cyst diagnosis and laminectomy surgery with or without fusion surgery were included in this study. Patients were tracked for SS 2 years after surgery. Laminectomy patients were propensity score-matched to laminectomy with fusion (LF) patients using a 2:1 ratio. The log-rank test and Cox regression were used to compare the cumulative incidence of SS between groups. RESULTS: There were 7664 and 1631 patients treated with laminectomy and LF before matching. After matching, there were 2212 laminectomy and 1631 LF patients and patient characteristics were balanced. The 2-year incidence of recurrent SS was 3.1% ([CI]: 2.2%, 4.0%) and 1.7% (95% CI: 0.9%, 2.5%) laminectomy and LF, respectively. Compared with laminectomy, LF had a statistically significant lower risk of recurrent SS (hazard ratio: 0.56 [95% CI: 0.32-0.97]; P -value: .04). CONCLUSION: All patients who had concomitant lumbar fusion showed decreased chance of having a cyst- or noncyst-related recurrence SS when compared with all patients undergoing laminectomy alone, regardless of diagnosis at the time of SS.

Unsupervised machine learning using K-means identifies radiomic subgroups of pediatric low-grade gliomas that correlate with key molecular markers.

INTRODUCTION: Despite advancements in molecular and histopathologic characterization of pediatric low-grade gliomas (pLGGs), there remains significant phenotypic heterogeneity among tumors with similar categorizations. We hypothesized that an unsupervised machine learning approach based on radiomic features may reveal distinct pLGG imaging subtypes. METHODS: Multi-parametric MR images (T1 pre- and post-contrast, T2, and T2 FLAIR) from 157 patients with pLGGs were collected and 881 quantitative radiomic features were extracted from tumorous region. Clustering was performed using K-means after applying principal component analysis (PCA) for feature dimensionality reduction. Molecular and demographic data was obtained from the PedCBioportal and compared between imaging subtypes. RESULTS: K-means identified three distinct imaging-based subtypes. Subtypes differed in mutational frequencies of BRAF (p < 0.05) as well as the gene expression of BRAF (p<0.05). It was also found that age (p < 0.05), tumor location (p < 0.01), and tumor histology (p < 0.0001) differed significantly between the imaging subtypes. CONCLUSION: In this exploratory work, it was found that clustering of pLGGs based on radiomic features identifies distinct, imaging-based subtypes that correlate with important molecular markers and demographic details. This finding supports the notion that incorporation of radiomic data could augment our ability to better characterize pLGGs.

Does Preoperative Opiate Choice Increase Risk of Postoperative Infection and Subsequent Surgery?

BACKGROUND: Opioids are commonly prescribed for chronic pain before spinal surgery and research has shown an increased rate of postoperative adverse events in these patients. OBJECTIVE: This study compared the incidence of 2-year subsequent surgical procedures and postoperative adverse events in patients undergoing lumbar fusion with or without 90-day preoperative opioid use. We hypothesized that patients using preoperative opioids would have a higher incidence of subsequent surgery and adverse outcomes. METHODS: A retrospective cohort study was performed using the Optum Pan-Therapeutic Electronic Health Records database including adult patients who had their first lumbar fusion between 2015 and 2018. The daily average preoperative opioid dosage 90 days before fusion was determined as morphine equivalent dose and further categorized into high dose (morphine equivalent dose >100 mg/day) and low dose (1-100 mg/day). Clinical outcomes were compared after adjusting for confounders. RESULTS: A total of 23,275 patients were included, with 2112 patients (10%) using opioids preoperatively. There was a significantly higher incidence of infection compared with nonusers (12.3% vs. 10.1%; P = 0.01). There was no association between subsequent fusion surgery (7.9% vs. 7.5%; P = 0.52) and subsequent decompression surgery (4.1% vs. 3.6%; P = 0.3) between opioid users and nonusers. Regarding postoperative infection risk, low-dose users showed significantly higher incidence (12.7% vs. 10.1%; P < 0.01), but high-dose users did not show higher incidence than nonusers (7.5% vs. 10.1%; P = 0.23). CONCLUSIONS: Consistent with previous studies, opioid use was significantly associated with a higher incidence of 2-year postoperative infection compared with nonuse. Low-dose opioid users had higher postoperative infection rates than did nonusers.

The ASNR-MICCAI Brain Tumor Segmentation (BraTS) Challenge 2023: Intracranial Meningioma.

Meningiomas are the most common primary intracranial tumor in adults and can be associated with significant morbidity and mortality. Radiologists, neurosurgeons, neuro-oncologists, and radiation oncologists rely on multiparametric MRI (mpMRI) for diagnosis, treatment planning, and longitudinal treatment monitoring; yet automated, objective, and quantitative tools for non-invasive assessment of meningiomas on mpMRI are lacking. The BraTS meningioma 2023 challenge will provide a community standard and benchmark for state-of-the-art automated intracranial meningioma segmentation models based on the largest expert annotated multilabel meningioma mpMRI dataset to date. Challenge competitors will develop automated segmentation models to predict three distinct meningioma sub-regions on MRI including enhancing tumor, non-enhancing tumor core, and surrounding nonenhancing T2/FLAIR hyperintensity. Models will be evaluated on separate validation and held-out test datasets using standardized metrics utilized across the BraTS 2023 series of challenges including the Dice similarity coefficient and Hausdorff distance. The models developed during the course of this challenge will aid in incorporation of automated meningioma MRI segmentation into clinical practice, which will ultimately improve care of patients with meningioma.

Safety and efficacy of salvage therapy with laser interstitial thermal therapy for malignant meningioma refractory to cesium-131 brachytherapy: illustrative case.

BACKGROUND: Anaplastic meningioma are rare, cancerous tumors of the central nervous system that often require multimodal therapy for tumor control. Both laser interstitial thermal therapy (LITT) and brachytherapy with implanted cesium-131 metallic seeds have demonstrated efficacy in the treatment of recurrent and resistant anaplastic meningioma; however, their safety as a dual therapy has never been reported. OBSERVATIONS: In this report, the authors present a case of a 53-year-old female who received LITT in combination with brachytherapy after surgical and radiation treatment options had been exhausted. The authors discuss the unique safety concern of thermal injury with this treatment combination and demonstrate their method for the safe administration of these treatments together. Furthermore, the authors provide a review of the literature on LITT as an emerging therapy for anaplastic meningioma. LESSONS: The use of LITT in combination with brachytherapy remains an option for salvage therapy in patients with recurrent meningioma that provides durable local control of tumor.

Intraoperative chyle leak repair during right-sided anterior cervical discectomy and fusion.

Iatrogenic chyle leak (CL) following lymphatic vessel damage is an uncommon but serious complication of neck dissections. In the setting of anterior cervical discectomy and fusion (ACDF), left-sided CL are an exceedingly rare complication, with an incidence of only 0.02 %. Only three cases of right-sided CL during an ACDF have been reported. The case presented is the first right-sided CL to be successfully identified intraoperatively and treated. Intraoperative and postoperative management are discussed. This case will hopefully bring clinical and surgical awareness to providers caring for patients undergoing an ACDF.

Hypoglossal nerve injury with C1 lateral mass screw placement: A case report and review of the literature.

We report the case of a 62-year-old man who presented with a progressive myelopathy secondary to spinal cord compression from an odontoid process fracture and subaxial central canal stenosis. The patient underwent a C1-T2 posterior decompression and instrumented fusion (PCDF) and did well immediately postoperatively. However, on POD1, he developed a right hypoglossal nerve (HN) palsy attributed to direct mechanical compression or injury from the C1 lateral mass screw (LMS), which improved following a revision and screw replacement. While HN injury is a known complication of high anterior and anterolateral cervical spine approaches as well as transcondylar screw fixation, this case aims to expand on the limited reports available regarding hypoglossal nerve injury following placement of bicortical C1 LMS. Furthermore, the use of fluoroscopic guidance in addition to anatomic landmarks and triggered electromyography of the tongue are offered as potential solutions to prevent HN injury intraoperatively.