Gliosarcoma with PNET features mimicking a metastatic neuroendocrine carcinoma: A diagnostic dilemma.

OBJECTIVE: Gliosarcomas (GS) comprise ~ 2 - 8% of glioblastomas and are associated with a similar poor prognosis. GS have rarely been found with a primitive neuroectodermal component (PNET). We present a case of gliosarcoma with PNET features (GS-PNET) that mimicked a neuroendocrine carcinoma on initial biopsy. MATERIALS AND METHODS: A 68-year-old male presented with 2 weeks of increasing headaches and difficulties with reading, writing, and word-finding. He was found to have a left-sided parieto-occipital heterogeneously enhancing mass. RESULTS: Pathologic analysis after surgical resection initially diagnosed a poorly differentiated carcinoma with neuroendocrine features, and adjuvant therapy was guided by this diagnosis as well as systemic imaging, which was suggestive of gastrointestinal primary malignancy with central nervous system (CNS) metastasis. Subsequent progression and re-resection established a diagnosis of GS with PNET component. Genomic profiling showed shared PTEN, TERT promotor, and TP53 mutations in the original and recurrent tumors. CONCLUSION: There have only been 5 previously reported cases of GS-PNET, to our knowledge, with this case representing the first with comprehensive molecular profiling. The case also highlights the importance of further work-up of presumed metastatic carcinoma with indeterminate immunostaining and/or suspected non-epithelioid component.

Assessment of vascularity in glioblastoma and its implications on patient outcomes.

There is little data on why glioblastomas (GBM) hemorrhage and how it may affect patient outcomes. The aim of this study was to investigate the mechanisms of hemorrhage in glioblastoma by examining molecular and genetic features by immunohistochemistry (IHC) and mRNA expression profiles in association with imaging and clinical outcomes. An observational retrospective cohort analysis was performed on 43 FFPE GBM tissue samples. MR images were assessed for the presence of hemorrhage and extent of resection. Specimens were examined for CD34 and CD105 expression using IHC. Tumor mRNA expression profiles were analyzed for 92 genes related to angiogenesis and vascularity. Forty-three specimens were analyzed, and 20 showed signs of hemorrhage, 23 did not. The average OS for patients with GBM with hemorrhage was 19.12 months (95% CI 10.39-27.84), versus 13.85 months (95% CI 8.85-18.85) in those without hemorrhage (p > 0.05). Tumors that hemorrhaged had higher IHC staining for CD34 and CD105. mRNA expression analysis revealed tumor hemorrhage was associated with increased expression of HIF1α and MDK, and decreased expression of F3. Hemorrhage in GBM was not associated with worsened OS. Increased expression of angiogenic factors and increased CD34 and CD105 IHC staining in tumors with hemorrhage suggests that increased hypoxia-induced angiogenesis and vessel density may play a role in glioblastoma hemorrhage. Characterizing tumors that are prone to hemorrhage and mechanisms behind the development of these hemorrhages may provide insights that can lead to the development of targeted, individualized therapies for glioblastoma.

Endoscopic Endonasal Transpterygoid Approach and the Need for Myringotomy.

OBJECTIVE: The expanded endonasal transpterygoid approach (EETA) is used to access the middle and posterior fossa through the pterygoid process. Traditionally, the eustachian tube (ET) was resected during EETA, which often required subsequent myringotomy for inner ear drainage. Anterolateral transposition of the ET was proposed to decrease potential morbidity associated with resection. However, a comparison of resection versus transposition regarding the need for subsequent myringotomy has not been reported. METHODS: This is a retrospective cohort study of patients who underwent an EETA. Patient demographics, tumor characteristics, management of ET with resection versus transposition, and need for subsequent myringotomy were collected. Analysis was performed with JMP software in standard fashion and univariate and multivariate logistic regression analysis performed with a p < 0.05 was considered significant. RESULTS: Ninety-one patients underwent EETA for various malignant and benign tumors. Twenty-seven patients required myringotomy, with tumors of the pterygopalatine fossa accounting for the most common location (n = 8). Malignant pathology had the highest myringotomy rate compared to benign tumors (48.9% vs. 10.9%, p < 0.001), as did receiving postoperative radiation (p < 0.001), ET resection (p < 0.001), and increasing CPK class. Multivariate analysis of these variables suggests that only ET resection significantly correlated with the need for myringotomy (LR 7.97, p = 0.005). CONCLUSIONS: ET resection during EETA can lead to ET dysfunction and require myringotomy post-operatively, and patients should be counseled of this risk. Radiation treatment, malignant pathology, and CPK class, all reflecting situations where more extensive surgery was needed, were associated with the need for myringotomy on univariate analysis but did not reach significance with multivariate analysis. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1203-1207, 2024.

Supraorbital Eyebrow Approach for Translamina Terminalis Resection of Third Ventricle Metastasis: 2-Dimensional Operative Video.

Tumors involving the third ventricle are rare, accounting for 0.6%-0.9% of all brain tumors. This deep-seated cavity is surrounded by critical neurovascular structures, making safe surgical resection of lesions in this region challenging. Traditionally, tumors of the third ventricle have been approached through a craniotomy and microsurgical resection.1-4 The supraorbital keyhole approach is a minimally invasive technique that can be used with minimal retraction of the brain and limited craniotomy while establishing a surgical field comparable with what can be achieved using traditional transcranial approaches. In this video, we describe the case of a 54-year-old man who underwent a supraorbital eyebrow approach for translamina terminalis resection of papillary thyroid carcinoma metastasis to the third ventricle. A gross total resection was achieved. The results achieved in our series are comparable with previously published reports of patients who underwent surgical resection of metastatic lesions involving the third ventricle.5-11 The patient consented to the procedure and to the publication of his image.

Management of recurrent giant hemangiopericytoma: illustrative cases.

BACKGROUND: Hemangiopericytoma (HPC) is a rare malignancy accounting for 0.4% of intracranial tumors. HPCs are characterized by local aggressiveness, high rates of recurrence, and a tendency to metastasize to extracranial sites. These features make management of HPCs challenging, often requiring a combination of radical resection and radiation. Given their rarity, optimal treatment algorithms remain undefined. OBSERVATIONS: The authors report a series of four patients who underwent resection of intracranial HPC. Mean age at presentation was 49.3 years. Three patients had reoperation for progression of residual tumor, and one patient was surgically retreated for recurrence. One patient received adjuvant radiotherapy following initial resection, and three patients received adjuvant radiotherapy following resection of recurrent or residual disease. There was one death in the series. Average progression-free survival and overall survival following the index procedure were 32.8 and 82 months, respectively. Progression occurred locally in all patients, with metastatic recurrence in one patient. LESSONS: The current gold-standard treatment for intracranial HPC consists of gross-total resection followed by radiation therapy. This approach allows satisfactory local control; however, given the tendency for these tumors to recur either locally or distally within or outside of the central nervous system, there is a need for salvage therapies to improve long-term outcomes for patients.

Back Pain: Differential Diagnosis and Management.

Back pain is a common condition affecting millions of individuals each year. A biopsychosocial approach to back pain provides the best clinical framework. A detailed history and physical examination with a thorough workup are required to exclude emergent or nonoperative etiologies of back pain. The treatment of back pain first uses conventional therapies including lifestyle modifications, nonsteroidal anti-inflammatory drugs, physical therapy, and cognitive behavioral therapy. If these options have been exhausted and pain persists for greater than 6 weeks, imaging and a specialist referral may be indicated.

Influence of clinical and radiological parameters on the likelihood of neurological improvement after surgery for degenerative cervical myelopathy.

OBJECTIVE: Degenerative cervical myelopathy (DCM) is routinely treated with surgical decompression, but disparate postoperative outcomes are frequently observed, ranging from complete neurological recovery to persistent decline. Although numerous clinical and radiological factors have been independently associated with failure to improve, the relative impact of these proposed risk factors remains obscure. In this study, the authors assess the combined role of clinical and radiographic parameters in contributing to failure to attain neurological improvement after surgery. METHODS: A consecutive series of patients who underwent surgery for DCM between July 2013 and August 2018 at a single institution was identified from a prospectively maintained database. Retrospective chart review was undertaken to record perioperative clinical and radiographic parameters. Failure to improve on the last follow-up evaluation after surgery, defined as a change in modified Japanese Orthopaedic Association (mJOA) score less than 2, was the primary outcome in univariate and multivariate analyses. RESULTS: The authors included 183 patients in the final cohort. In total, 109 (59.6%) patients improved (i.e., responders with ΔmJOA score ≥ 2) after surgery and 74 (40.4%) were nonresponders with ΔmJOA score < 2. Baseline demographic variables and comorbidity rates were similar, whereas baseline Nurick score was the only clinical variable that differed between responders and nonresponders (2.7 vs 3.0, p = 0.02). In contrast, several preoperative radiographic variables differed between the groups, including presence and degree of cervical kyphosis, number of levels with bidirectional cord compression, presence and number of levels with T2-weighted signal change, intramedullary lesion (IML) length, Torg ratio, and both narrowest spinal canal and cord diameter. On multivariate analysis, preoperative degree of kyphosis at C2-7 (OR 1.19, p = 0.004), number of levels with bidirectional compression (OR 1.83, p = 0.003), and IML length (OR 1.14, p < 0.001) demonstrated the highest predictive power for nonresponse (area under the receiver operating characteristic curve 0.818). A risk factor point system that predicted failure of improvement was derived by incorporating these 3 variables. CONCLUSIONS: When a large spectrum of both clinical and radiographic variables is considered, the degree of cervical kyphosis, number of levels with bidirectional compression, and IML length are the most predictive of nonresponse after surgery for DCM. Assessment of these radiographic factors can help guide surgical decision-making and more appropriately stratify patients in clinical trials.

A modern approach to olfactory groove meningiomas.

OBJECTIVE: Management of olfactory groove meningiomas (OGMs) has changed significantly with the advances in extended endoscopic endonasal approaches (EEAs), which is an excellent approach for patients with anosmia since it allows early devascularization and minimizes retraction on the frontal lobes. Craniotomy is best suited for preservation of olfaction. However, not infrequently, a tumor presents after extending outside the reach of an EEA and a solely transcranial approach would require manipulation and retraction of the frontal lobes. These OGMs may best be treated by a staged EEA-craniotomy approach. In this study the authors' goal was to present their case series of patients with OGMs treated with their surgical approach algorithm. METHODS: The authors conducted an IRB-approved, nonrandomized historic cohort including all consecutive cases of OGMs treated surgically between 2010 and 2020. Patient demographic information, presenting symptoms, operative details, and complications data were collected. Preoperative and postoperative tumor and T2/FLAIR intensity volumes were calculated using Visage Imaging software. RESULTS: Thirty-one patients with OGMs were treated (14 craniotomy only, 11 EEA only, and 6 staged). There was a significant difference in the distribution of patients presenting with anosmia and visual disturbance by approach. Tumor size was significantly correlated with preoperative vasogenic edema. Gross-total resection was achieved in 90% of cases, with near-total resection occurring twice with EEA and once with a staged approach. T2/FLAIR hyperintensity completely resolved in 90% of cases and rates did not differ by approach. Complication rates were not significantly different by approach and included 4 CSF leaks (p = 0.68). CONCLUSIONS: A staged approach for the management of large OGMs with associated anosmia and significant lateral extension is a safe and effective option for surgical management. Through utilization of the described algorithm, the authors achieved a high rate of GTR, and this strategy may be considered for large OGMs.

A New Finding on Magnetic Resonance Imaging for Diagnosis of Hemifacial Spasm with High Accuracy and Interobserver Correlation.

Among patients with clinical hemifacial spasm (HFS), imaging exams aim to identify the neurovascular conflict (NVC) location. It has been proven that the identification in the preoperative exam increases the rate of surgical success. Despite the description of specific magnetic resonance image (MRI) acquisitions, the site of neurovascular compression is not always visualized. The authors describe a new MRI finding that helps in the diagnosis of HFS, and evaluate the sensitivity, specificity, and interobserver correlation of the described sign. A cross-sectional study including cases of hemifacial spasm treated surgically from 1 August 2011 to 31 July 2021 was performed. The MRIs of the cases were independently evaluated by two experienced neuroradiologists, who were blinded regarding the side of the symptom. The neuroradiologists were assigned to evaluate the MRIs in two separate moments. Primarily, they evaluated whether there was a neurovascular conflict based on the standard technique. Following this initial analysis, the neuroradiologists received a file with the description of the novel sign, named Prevedello Sign (PS). In a second moment, the same neuroradiologists were asked to identify the presence of the PS and, if it was present, to report on which side. A total of 35 patients were included, mostly females (65.7%) with a mean age of 59.02 (+0.48). Since the 35 cases were independently evaluated by two neuroradiologists, a total of 70 reports were included in the analysis. The PS was present in 66 patients (sensitivity of 94.2%, specificity of 91.4% and positive predictive value of 90.9%). When both analyses were performed in parallel (standard plus PS), the sensitivity increased to 99.2%. Based on the findings of this study, the authors conclude that PS is helpful in determining the neurovascular conflict location in patients with HFS. Its presence, combined with the standard evaluation, increases the sensitivity of the MRI to over 99%, without increasing risks of harm to patients or resulting in additional costs.

Endoscopic endonasal transclival petroclival meningioma resection.

Petroclival meningiomas are surgically challenging due to the surrounding neurovascular structures. Petroclival meningiomas located inferior to the oculomotor nerve and superior or medial to the abducens nerve are ideal for an endoscopic endonasal transclival approach because this prevents the need to work across cranial nerves, limiting operative risk. The authors present a case of a 45-year-old woman with a growing petroclival meningioma that was distorting the pons. In the video they demonstrate the technique and discuss nuances of petroclival meningioma resection via an endoscopic endonasal transclival approach with posterior clinoidectomy. The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21209.

Morphometric comparison of Fisch type A and endoscopic endonasal far-medial supracondylar approaches to the jugular foramen.

OBJECTIVE: The jugular foramen (JF) is one of the most complex and challenging skull base regions to approach surgically. The extreme medial approach to access the JF provides the approach angle from an anterior direction and does not require dissection and sacrifice of the jugular bulb (JB) to reach the pars nervosa. The authors compared the Fisch type A approach to the extreme medial approach to access the JF and evaluated the usefulness of the extreme medial approach. METHODS: This study was performed at the Anatomical Laboratory for Visuospatial Innovations in Otolaryngology and Neurosurgery of The Ohio State University. For the comparison of surgical maneuverability and visualization, two angles were measured: 1) the angle of attack (AoA), defined as the widest angle of movement achieved with a straight dissector; and 2) the angle of endoscopic exposure (AoEE), defined as the widest angle of movement in the nasal cavity. The differences in eustachian tube (ET) management, approach angle, surgical maneuverability, and surgical application of the Fisch type A approach to the extreme medial approach were compared. RESULTS: There was no difference between ET mobilization and transection regarding cranial-caudal (CC) or medial-lateral (ML) AoA (p = 0.646). The CC-AoA of the Fisch type A approach was significantly wider than the CC-AoA of the extreme medial approach (p = 0.001), and the CC-AoEE was significantly wider than the CC-AoA of the extreme medial approach (p < 0.001). There was no significant difference between the CC-AoA of the Fisch type A approach and the CC-AoEE. The ML-AoA of the Fisch type A approach was significantly wider than the ML-AoA of the extreme medial approach (p = 0.033), and the ML-AoEE was significantly wider than ML-AoA in the extreme medial approach (p < 0.001). The ML-AoEE was significantly wider than the ML-AoA in the Fisch type A approach (p = 0.033). CONCLUSIONS: The surgical maneuverability of the extreme medial approach was not inferior to that of the Fisch type A approach. The extreme medial approach can provide excellent surgical field visualization, while preserving the JB. Select cases of chordomas, chondrosarcomas, and JF schwannomas should be considered for an extreme medial approach. These two approaches are complementary, and a case-by-case detailed analysis should be conducted to decide the best approach.

Resident Night Float or 24-hour Call Hospital Coverage: Impact on Training, Patient Outcome, and Length of Stay.

OBJECTIVE: The impact of neurosurgical resident hospital coverage system, performed via a night float (12-hour shifts overnight) or a 24-hour call, on neurological surgery resident training and patient care is unknown. DESIGN: Retrospective review comparing night float and 24-hour call coverage on trainee surgical experience, elective time, annual program surveys, patient outcomes, and length of stay. SETTING: The Ohio State Wexner Medical Center Neurosurgery residency program, Columbus, Ohio. PARTICIPANTS: The neurosurgical residents from 2016 to 2019. RESULTS: Monthly cases performed by junior residents significantly increased after transitioning to a 24-hour call schedule (18 versus 30, p < 0.001). There were no differences for total cases among program graduates during this time (p = 0.7). Trainee elective time significantly increased after switching to 24-hour call coverage (18 versus 24 months after the transition; p = 0.004). Risk-adjusted mortality and length of stay indices were not different (0.5 versus 0.3, p = 0.1; 0.9 versus 0.9; p = 0.3). Program surveys had minimal change after the transition to 24-hour call. CONCLUSIONS: Transitioning from a night float to a 24-hour call coverage system led to improved junior resident case volume and elective time without detrimental effect on patient-related outcomes.

A Case Series of the Use of Piezosurgery Instrument for Minimally Invasive Metopic Suturectomy.

BACKGROUND: Minimal invasive suturectomy is one of the many surgical approaches to treat isolated single suture craniosynostosis. This approach can be technically challenging in metopic craniosynostosis given the narrow corridor and steep angle of the forehead. New instruments such as the Piezosurgery device (Mectron) have the potential to improve the ability to safely perform minimal invasive surgery in metopic craniosynostosis. OBJECTIVE: To demonstrate the safety and efficacy of Piezosurgery technology in minimal invasive suturectomy for nonsyndromic metopic suture craniosynostosis and to describe our technique. METHODS: A retrospective chart review was performed of all the single metopic suturectomies performed at our single institution from March 2018 to November 2019. Pre-, intra-, and postoperative data were collected to assess the safety of Piezosurgery. RESULTS: The cohort consisted of 12 patients with an average of 95.25 d old and an average weight of 6.2 kg. A total of 91.7% were male, and 91.7% were Caucasian. There were no intraoperative or postoperative Piezosurgery device-related complications in the entire cohort. CONCLUSION: The use of the Piezosurgery instrument was safe in this cohort of minimal invasive metopic suturectomy. This device has greatly increased the ease of this procedure in our hands.

Simultaneous Endoscopic and Microscopic Visualization in Microvascular Decompression for Hemifacial Spasm.

BACKGROUND: Hemifacial spasm (HFS) is a socially limiting condition leading to decreased quality of life that can be treated with microvascular decompression (MVD). Endoscopy has been described as an adjunct to traditional microscopy for MVD, although the best visualization technique is debated. OBJECTIVE: To review the current literature on use of endoscopy in MVD for HFS and to describe the simultaneous microscopic and endoscopic visualization technique along with a video illustration. METHODS: Patients who underwent MVD for HFS were retrospectively reviewed from January 2011 to December 2019. The first set of patients in the series were done using traditional endoscopic assisted visualization, followed by a change in technique in the subsequent patients using the simultaneous endoscopic technique. The surgical technique is described as well as illustrated with a video. RESULTS: In total, 21 patients underwent 24 MVDs to treat HFS. The simultaneous endoscopic/microscopic technique was used in 48% of cases for visualization. All but one patient had resolution of their symptoms immediately after the procedure. In total, 7 patients had recurrence of HFS, with 4 (17%) resolving spontaneously and 3 (13%) ultimately undergoing redo MVD. Postoperatively 7 patients (29%) had transient complications that all resolved completely. There was no significant difference between the traditional alternating microscopic and endoscopic technique with the simultaneous endoscopic microscopic technique. CONCLUSION: Endoscopic assistance during MVD for HFS is beneficial and may be streamlined by using the simultaneous microscope and endoscope visualization technique.

Correlation Between Neurosurgical Residency Written Board Scores and Case Logs.

OBJECTIVE: There are few objective measures for evaluating individual performance throughout surgical residency. Two commonly used objective measures are the case log numbers and written board examination scores. The objective of this study was to investigate possible correlations between these measures. METHODS: We conducted a retrospective review of the American Board of Neurological Surgery (ABNS) written board scores and the Accreditation Council for Graduate Medical Education case logs of 27 recent alumni from neurologic surgery residency training programs at The Ohio State Wexner Medical Center and the University of Nebraska Medical Center. RESULTS: The number of spine cases logged was significantly correlated with the ABNS written examination performance in univariate linear regression (r2 = 0.182, P = 0.0265). However, case numbers from all other neurosurgical subspecialties did not significantly correlate with ABNS written board performance (P > 0.1). CONCLUSIONS: Identifying which objective measures correlate most closely with resident education could help optimize the structure of residency training programs. We believe that early exposure to focused aspects of neurosurgery helps the young resident learn quickly and efficiently and ultimately score highly on standardized examinations. Therefore program directors may want to ensure focused exposure during the early years of residency, with particular attention to worthwhile rotations in spine neurosurgery.