Alexander S. G. Micko, Omar Keritam, Wolfgang Marik, Ben A. Strickland, Robert G. Briggs, Shane Shahrestani, Tyler Cardinal, Engelbert Knosp, Gabriel Zada, and Stefan Wolfsberger
Dumbbell-shaped pituitary adenomas (DSPAs) are prone to a nondescending suprasellar tumor component and are at risk for residual tumor or postoperative bleeding. In a multicenter retrospective cohort analysis, the authors found the neck-to-dome area ratio of prognostic value for prediction of intraoperative tumor nondescent in DSPAs operated on via a direct endonasal endoscopic approach. If nondescent is anticipated from preoperative MRI, the surgeon should be prepared for early second subfrontal decompression or consider an extended approach as the primary option.
Xiaopeng Guo, Ruopeng Zhang, Duoxing Zhang, Zihao Wang, Lu Gao, Yong Yao, Kan Deng, Xinjie Bao, Ming Feng, Zhiqin Xu, Yi Yang, Wei Lian, Renzhi Wang, Wenbin Ma, and Bing Xing
In this prospective, longitudinal cohort study with 659 acromegaly patients, the authors investigated the immediate and long-term endocrine outcomes after initial transsphenoidal surgery based on the strict 2010 remission criteria, analyzed the clinical determinants, and explored the patterns of outcome changes during a long follow-up (median 51 months). This study will assist in informing patient consultations on possible treatment outcomes and planning for individualized adjuvant treatments in advance.
The authors aimed to validate predictive factors for recovery from adult growth hormone deficiency (AGHD) after transsphenoidal surgery (TSS) in patients with nonfunctioning pituitary adenoma (NFPA). The predictive factors for recovery from AGHD after TSS were initial rather than repeated TSS, younger age (≤ 62.2 years), and high peak GH level (≥ 0.74 μg/L) determined by preoperative pituitary provocation test. The study results indicate that whether TSS for NFPA can promote recovery from AGHD is worth considering in some patients.
Serge Makarenko, Ibrahim Alzahrani, Michael Karsy, Chandrasekhar Deopujari, and William T. Couldwell
Because management of giant pituitary macroadenomas presents a significant challenge, the authors describe surgical nuances and outcomes in the treatment of a large series of patients with these lesions. Gross-total resection was only 38.9%, but tumor stability was achieved in 71.3% with a morbidity rate of 11.1%. Surgical goals for removal of giant pituitary tumors should include attempts at maximal safe resection to minimize the risk of residual tumor apoplexy by tailoring the approach along the major axis of the tumor.
Rushikesh S. Joshi, Matheus P. Pereira, Robert C. Osorio, Taemin Oh, Alexander F. Haddad, Kaitlyn M. Pereira, Kevin C. Donohue, Zain Peeran, Sweta Sudhir, Saket Jain, Angad Beniwal, Ankush Chandra, Seunggu J. Han, John D. Rolston, Philip V. Theodosopoulos, Sandeep Kunwar, Lewis S. Blevins Jr., and Manish K. Aghi
This study examines pre- and perioperative risk factors for diabetes insipidus (DI) among more than 2500 transsphenoidal surgery patients. Intraoperative CSF encounter, craniopharyngioma diagnosis, postoperative hyponatremia, and young age all increased the risk of postoperative DI. When solely examining pituitary adenomas, young age and CSF encounter increased DI risk. As the largest patient series on this topic, this study identifies which patients should be more diligently followed to quickly identify and treat postoperative DI.
Eric J. Chalif, William T. Couldwell, and Manish K. Aghi
There are few prior studies of giant pituitary adenomas (≥ 4 cm at maximum diameter) and those that exist are from high-volume institutions whose outcomes may not be representative of many cancer centers. In this study, 3696 adults with giant pituitary adenomas were identified from a large national cancer registry. This population had significantly worse morbidity and mortality than did patients with nongiant pituitary adenomas. Outcomes were significantly better at high-volume facilities than low-volume facilities.
The authors aimed to assess aneurysm wall enhancement (AWE) in unruptured posterior communicating artery (PcomA) aneurysms with oculomotor nerve palsy, which can be a subgroup of evolving aneurysms with high rupture risk. The degree of AWE in PcomA aneurysms with oculomotor nerve palsy was higher than that in asymptomatic growing PcomA aneurysms. This finding suggests the potential utility of AWE for risk stratification in evolving aneurysms.
Qingyuan Liu, Xinyi Leng, Junhua Yang, Yi Yang, Pengjun Jiang, Maogui Li, Shaohua Mo, Shuzhe Yang, Jun Wu, Hongwei He, and Shuo Wang
Accurate stratification of the stability of unruptured intracranial aneurysms (IAs) is crucial to guide treatment decisions in affected patients. In this prospective study, the authors aimed to develop multidimensional models to predict the 2-year stability of unruptured IAs treated conservatively, incorporating clinical features, morphological features, and adjacent hemodynamic features. The multidimensional models had higher predictive accuracies than previous models, which may yield a valuable tool for individualized risk assessment of unruptured IAs in the anterior circulation.
Samuel J. Cler, David C. Lauzier, Arindam R. Chatterjee, Joshua W. Osbun, Christopher J. Moran, and Akash P. Kansagra
The authors retrospectively assessed the safety, efficacy, and scale of off-label aneurysm treatment with the Pipeline embolization device at an experienced center. Across 416 aneurysms, they found that off-label use was common and had similar efficacy as on-label use, but with a higher rate of ischemic complications that was within the prespecified safety criteria of earlier trials but nonetheless demands attention. These performance data highlight the scale and feasibility of off-label use of the Pipeline embolization device in real-world practice.
Kapilan Panchendrabose, Sandeep Muram, Brooke L. Belanger, Muneer Eesa, Mohammed A. Almekhlafi, Mayank Goyal, John H. Wong, Arindom Sen, Bijoy K. Menon, Bryan Har, and Alim P. Mitha
The authors attempted to determine whether an intra-arterial injection of mesenchymal stem cells (MSCs) after endovascular stent placement in an animal model would improve endothelialization and reduce thrombus formation. Optical coherence tomography showed improved endothelialization following MSC injection, but there was no effect on thrombus formation. MSCs may be exploited to augment the integration of endovascular stents into the vessel wall, but additional studies are needed to determine the durability and mechanism of this effect.
Han Yan, Lior M. Elkaim, Flavia Venetucci Gouveia, Joelene F. Huber, Jurgen Germann, Aaron Loh, Juan Carlos Benedetti-Isaac, Paresh K. Doshi, Cristina V. Torres, David J. Segar, Gavin J. B. Elias, Alexandre Boutet, G. Rees Cosgrove, Alfonso Fasano, Andres M. Lozano, Abhaya V. Kulkarni, and George M. Ibrahim
Through this multicenter collaboration, a connectomic analysis was performed in patients with autism spectrum disorder (ASD) who manifested extreme behaviors and underwent deep brain stimulation (DBS). Stimulation of different targets engaged similar brain circuitry closely related to the anterior limb of the internal capsule. The current work elucidates putative mechanisms by which DBS could improve symptoms of extreme behaviors in patients with ASD.
Jennifer A. Sweet, Keming Gao, Zhengyi Chen, Curtis Tatsuoka, Joseph R. Calabrese, Martha Sajatovic, Jonathan P. Miller, and Cameron C. McIntyre
Although bipolar disorder is a leading cause of disability globally, little is known about why some patients respond to therapy and others are refractory, precluding the development of an effective treatment for patients with refractory disease. The authors investigated brain circuitry in subjects with refractory bipolar disorder compared to subjects responsive to therapy and healthy controls. Key differences between groups were identified, suggesting that aberrant brain circuitry in patients with refractory disease may represent a future surgical target for deep brain stimulation.
Karen J. Kluin, James M. Mossner, Joseph T. Costello, Kelvin L. Chou, and Parag G. Patil
The authors examined the types and prevalence of motor speech changes with subthalamic nucleus deep brain stimulation (DBS) for Parkinson's disease, as well as their relationship to preoperative speech, intraoperative testing, and postoperative lead localization. They found that intraoperative motor speech examination strongly predicted postoperative outcomes and that stimulation sites associated with maximal Movement Disorder Society Unified Parkinson's Disease Rating Scale improvement and worsened dysarthria were distinct. This study indicated that DBS electrode repositioning could reduce dysarthria while maintaining motor improvement.
Asra Askari, Taylor R. Greif, Jordan Lam, Amanda C. Maher, Carol C. Persad, and Parag G. Patil
The authors investigated potential causes of verbal fluency decline in subthalamic nucleus deep brain stimulation (STN DBS) for Parkinson disease. They found that DBS lead penetration of a Broca area to (lateral) superior frontal gyrus fiber pathway negatively impacted verbal fluency more than did active contact location. Avoidance of the Broca–lateral SFG pathway during surgical planning may spare verbal fluency while preserving excellent motor outcomes in STN DBS for Parkinson disease.
Panagiotis Kerezoudis, Brian N. Lundstrom, Fredric B. Meyer, Gregory A. Worrell, and Jamie J. Van Gompel
The authors summarized existing evidence on resection, ablation, and neuromodulation for refractory epilepsy rising from the primary sensorimotor cortex. Open resection of seizure foci remains to date the most effective treatment for seizure freedom; however, it is associated with a nonnegligible permanent deficit rate. Neuromodulation has been shown to offer promising results with minimal morbidity. The authors devised a treatment algorithm for providers and researchers on how to approach central lobule epilepsy.
Yuanzhi Xu, Ahmed Mohyeldin, Maximiliano Alberto Nunez, Ayoze Doniz-Gonzalez, Vera Vigo, Aaron A. Cohen-Gadol, and Juan C. Fernandez-Miranda
The authors investigated the microvascularization of the hippocampus in high-quality anatomical specimens and propose a topographical classification into 3 arterial complexes—the anterior, middle, and posterior hippocampal arterial complexes—which irrigate the hippocampal head, body, and tail, respectively. The anterior hippocampal, anterior longitudinal hippocampal, and posterior longitudinal hippocampal veins drain the hippocampal head, body, and tail, respectively, into the basal and internal cerebral veins. A detailed understanding of the microvascular anatomy of the hippocampus improves surgical planning and execution for medial temporal tumor surgery.
Travis S. Tierney, Kambiz N. Alavian, Nolan Altman, Sanjiv Bhatia, Michael Duchowny, Ann Hyslop, Prasanna Jayakar, Trevor Resnick, Shelly Wang, Ian Miller, and John Ragheb
MRI-guided high-frequency focused ultrasound can pass through the scalp and skull to precisely heat and destroy tissue in the brain. Currently, this treatment is approved only for use in adults with movement disorders. This study showed that deep brain lesions can be treated safely in subjects aged 15–22 years old. The trial is ongoing and hopes to enroll children as young as 8 years old and lead to an expanded trial to show efficacy.
Pablo E. Saucedo-Alvarado, Ana Luisa Velasco, Gustavo Aguado-Carrillo, Manola Cuellar-Herrera, David Trejo-Martínez, Rene Márquez-Franco, and Francisco Velasco-Campos
The authors sought to determine if deep brain stimulation (DBS) of the parahippocampal cortex (PHC) induced seizure control in patients with severe hippocampal sclerosis, who have been observed to have delayed and less significant improvement in response to DBS treatment compared with other patients. The study results showed that PHC DBS induced immediate 80% seizure control. The study findings are important because they demonstrate that PHC DBS is a safe and effective treatment for patients with refractory temporal lobe epilepsy who are not candidates for resective surgery.
Jessica C. Eaton, Madeline E. Greil, Dominic Nistal, David J. Caldwell, Emily Robinson, Zaid Aljuboori, Nancy Temkin, Robert H. Bonow, and Randall M. Chesnut
The authors explored complication-related factors influencing cranioplasty timing following traumatic brain injury (TBI), as the "3-month rule" is unfounded but widely quoted. No difference was found in the incidence of complications when the time after craniectomy was divided into early (≤ 90 days), intermediate (91–180 days), and late (> 180 days) periods, or for a subset of "ultra-early" procedures. Demonstrating the safety of early cranioplasty allows us to realize its clinical and systemic benefits after TBI (e.g., fewer trephination-syndrome effects, shorter length of stay, and fewer readmissions).
The aim of this study was to validate the efficacy and safety of the updated Brain Injury Guidelines (uBIG) for complicated mild traumatic brain injury. The authors found that the uBIG accurately identified high-risk patients who died or received neurosurgical intervention. These results could lead to the implementation of a new clinical decision rule like the uBIG in emergency departments to care for patients with complicated mild traumatic brain injury.
Saniya Mediratta, Jacob R. Lepard, Ernest J. Barthélemy, Jacquelyn Corley, and Kee B. Park
This study aimed to characterize barriers to delivering neurotrauma care in low- to middle-income countries from the perspective of local neurotrauma providers by using the Lancet Global Surgery metrics and Three Delays framework. Nearly 3.4 billion people were estimated to be at risk for impoverishing expenditure and 2.9 billion were at risk for catastrophic expenditure in paying for neurotrauma care. The most significant causes for delays were those related to reaching care, with all delays correlating to income classification and geographic region.
Thorbjørn Søren Rønn Jensen, Mette Haldrup, Mads Hjortdal Grønhøj, Rares Miscov, Carl Christian Larsen, Birgit Debrabant, Frantz Rom Poulsen, Bo Bergholt, Torben Hundsholt, Carsten Reidies Bjarkam, and Kåre Fugleholm
Use of a postoperative drain is considered mandatory, but uniformity among neurosurgeons regarding optimal drainage time is lacking. With a simple study design, patients received identical care in the first 24 hours postoperatively, after which randomization was disclosed and drains were removed immediately or maintained for an additional 24 hours. The authors found no statistically significant differences in the 90-day rates of chronic subdural hematoma recurrence, death, or complications between patients who received 24 hours of drainage and those who received 48 hours. The authors expect a large impact worldwide due to evidence-based reduction in drain duration to 24 hours.
Rebecca Ronsley, Eric Bouffet, Peter Dirks, James Drake, Abhaya Kulkarni, and Ute Bartels
The aim of this study was to describe the management of hydrocephalus in a cohort of pediatric patients with germinoma. In children with germinoma, hydrocephalus was successfully managed with a temporary external ventricular drain without the need for shunt placement in most cases. This study demonstrates that timely initiation of chemotherapy is imperative to rapidly reduce tumor bulk in children with germinoma and limits the need for ventriculoperitoneal shunt insertions.
Umberto Tosi, Rafael Uribe-Cardenas, Jacques Lara-Reyna, Francis N. Villamater, Imali Perera, Philip E. Stieg, Apostolos John Tsiouris, and Mark M. Souweidane
Endoscopic colloid cyst removal relies on a transforaminal corridor, but colloid cysts between the fornices and leaflets of the septum pellucidum are not amenable to a transforaminal route. The objective of this paper was to describe the anatomical features of and endoscopic technique for intraseptal colloid cysts. The authors provide convincing evidence that this colloid cyst variant can be treated with an endoscopic transseptal-interforniceal approach, thus expanding the established benefits of neuroendoscopy to patients with this variant.
Wentao Zheng, Peng Zhao, Haidong Song, Bo Liu, Jingru Zhou, Cungang Fan, Dongliang Wang, and Ruen Liu
The authors investigated the prognostic factors for long-term clinical outcomes in patients who underwent microvascular decompression for glossopharyngeal neuralgia. Venous compression of the glossopharyngeal nerve root entry zone and lower degree of neurovascular conflict were identified as independent predictors for adverse pain-free survival in this population. These findings may contribute to better preoperative assessment and postoperative management for the treatment of glossopharyngeal neuralgia.
Mayur Sharma, Tyler Ball, Dengzhi Wang, Beatrice Ugiliweneza, Abbas Rattani, Shiao Woo, Maxwell Boakye, Joseph S. Neimat, Brian Williams, and Norberto Andaluz
In this study, researchers compared the healthcare utilization in elderly patients with trigeminal neuralgia (TN) managed using surgery, radiosurgery (RS), or percutaneous techniques (PTs). Surgery was the most durable procedure with the least number of subsequent procedures, followed by RS and PTs over 5 years. PTs resulted in the highest utilization of healthcare resources and need for reoperations. These findings may be considered for informed decision-making in elderly patients with TN.
Dhiraj J. Pangal, Guillaume Kugener, Tyler Cardinal, Elizabeth Lechtholz-Zey, Casey Collet, Sasha Lasky, Shivani Sundaram, Yichao Zhu, Arman Roshannai, Justin Chan, Aditya Sinha, Andrew J. Hung, Animashree Anandkumar, Gabriel Zada, and Daniel A. Donoho
The objective of this study was to use video-based features to accurately quantify surgical tool movement and predict surgical skill (outcomes) of 73 surgeons who attempted to manage a bleeding complication in a cadaveric training exercise. The authors found that these video-based automated performance metrics can accurately predict task success by the surgeon and blood loss. These findings motivate the further development of surgical data science techniques to quantify surgical technique.
Nathan A. Shlobin, Roxanna M. Garcia, and Mark Bernstein
This paper provides an overview of the emerging field of neuropalliative care. Individuals living with neurosurgical conditions have unique palliative care needs. Neurosurgeons have the potential to play an important role within multidisciplinary neuropalliative care teams but often lack formal training in palliative care skills. This study highlights the current state of palliative care within neurosurgery, identifies competencies for neurosurgeons, and delineates future priorities for this subfield.
Jonathan H. Borden, Uma V. Mahajan, Lud Eyasu, William Holden, Brian Shaw, Peter Callas, and Deborah L. Benzil
Researchers assessed the diversity of neurosurgery residents via diversity indices and whether a medical school’s intrinsic academic opportunities and resources relate to the number of residents produced. Neurosurgery residents are less diverse than medical students, and top-40 ranked research medical schools are significantly overrepresented within neurosurgery residents. Preliminary results suggested that neurosurgery’s challenge in achieving the desired diversity may relate to uneven attraction and/or recruitment across an increasingly diverse medical student body.
Sudheesha Perera, Shawn L. Hervey-Jumper, Praveen V. Mummaneni, Ernest J. Barthélemy, Alexander F. Haddad, Dario A. Marotta, John F. Burke, Andrew K. Chan, Geoffrey T. Manley, Phiroz E. Tarapore, Michael C. Huang, Sanjay S. Dhall, Dean Chou, Katie O. Orrico, and Anthony M. DiGiorgio
This project set out to determine the socioeconomic correlates with the neurosurgical workforce in the US. Key findings include greater average distances to access neurosurgical care for Hispanic and Native American populations. Methods to reduce these disparities are still to be determined.
Robert Romano, Debraj Mukherjee, L. Madison Michael II, Judy Huang, M. Harrison Snyder, Vamsi P. Reddy, Katherine Guzman, Pamela Lane, Jeremiah N. Johnson, Nathan R. Selden, Stacey Q. Wolfe, and on behalf of the Society of Neurological Surgeons
This article describes thoughts and concerns from neurosurgery applicants regarding the virtual recruitment format necessitated by the COVID-19 pandemic. The applicants demonstrated overwhelming support for a mix of virtual and in-person recruitment, with their biggest concern the impaired ability to assess program culture. Applicants highlighted opportunities to improve the recruitment experience, including optimized interview invitation release, centralized scheduling methods, and interview caps for applicants.
Andy Y. Wang, Diang Liu, Joseph N. Tingen, Harleen Saini, Vaishnavi Sharma, Alexandra Flores, and Ron I. Riesenburger
The authors present a biographical sketch of Dr. William Beecher Scoville, an important neurosurgical figure in the 20th century. It details the complexities of a pioneering neurosurgeon's journey, his early life and interests, innovations and discoveries, leadership in neurosurgical societies, and psychosurgical work. They uncover original discoveries and materials, and concisely assemble one of the most comprehensive accounts available of Dr. Scoville's life and legacy.
TO THE EDITOR: We read with great interest the article by Antar et al.1 (Antar A, Feghali J, Wicks EE, et al. Which medical schools produce the most neurosurgery residents? An analysis of the 2014–2020 cohort. J Neurosurg. 2022;137:283-295). In this study, the authors aimed to delineate which US medical schools have produced the most neurosurgery residents during the 2014–2020 match period. These authors also identified the following factors most commonly associated with a higher mean percentage of graduates entering neurosurgery: number of clinical neurosurgery faculty, presence of a neurosurgery interest group or home
TO THE EDITOR: We read with interest the article by Shibahashi et al.1 (Shibahashi K, Ohbe H, Yasunaga H. Adjuvant oral tranexamic acid and reoperation after burr hole surgery in patients with chronic subdural hematoma: propensity score–matched analysis using a nationwide inpatient database. J Neurosurg. Published online July 22, 2022. doi:10.3171/2022.5.JNS22664). In their propensity score–matched analysis of adjuvant oral tranexamic acid (TXA) after burr hole surgery for chronic subdural hematoma (CSDH), the authors found that adjuvant TXA use was associated with significantly lower reoperation rates and hospitalization costs.
Researchers used brief brain stimulation sessions and deep learning to localize where seizures originated in people with epilepsy. Typically, people must stay in the hospital for many weeks to properly localize seizure onset regions. However, these regions can be localized in less than an hour by using brief stimulation and deep learning. These techniques could rapidly expedite presurgical workup and augment surgical decision-making.
The compendia of medical knowledge of the great ancient Indian physicians Suśruta, Caraka, Jīvaka, and Vāgbhaṭa all attest to the practice of neurosurgery and neurology starting in the 1st millennium bce. Although a period of scientific stagnation ensued between the 12th and 20th centuries ce, Indian medical neurosciences once again flourished after India’s independence from British rule in 1947. The pioneers of modern Indian neurosurgery, neurology, and their ancillary fields made numerous scientific and clinical discoveries, advancements, and innovations that proved influential on a global scale. Most importantly, the efforts of Indian neurosurgeons and neurologists were unified at the national level through the Neurological Society of India, which was established in 1951 and enabled an unprecedented degree of collaboration within the aforementioned medical specialties. The growth and success of the Indian model bears several lessons that can be applied to other nations in order to garner better collaboration among neurosurgeons, neurologists, and physicians in related fields. Here, the authors elaborate on the origins, growth, and development of neurosurgery and neurology in India and discuss their current state in order to glean valuable lessons on interdisciplinary collaboration, which forms the basis of the authors’ proposal for the continued growth of societies dedicated to medical neurosciences across the world.
The authors evaluated the risk factors for 5-year prospective hemorrhage and developed a predictive nomogram based on an observational brainstem cavernous malformation (BSCM) series. The nomogram showed convincing predictive power and accurately differentiated patients from three different risk groups. This preoperative grading system quantitatively informs patients of their possibility of future hemorrhage and distinguishes aggressive cases from silent ones to provide new evidence for individualized therapeutic strategies.
Cerebrospinal fluid in the lateral end of a vestibular schwannoma within the internal auditory canal is called a fundal fluid cap. This study evaluated its clinical impact on postoperative facial nerve function. The authors found that patients with a fundal fluid cap had a better chance of favorable facial nerve function after microsurgery. This radiographic sign can be used to predict the risk of postoperative facial nerve dysfunction and assist with preoperative decision-making regarding treatment strategy.
In this study the authors aimed to understand the clinical relevance to glioma risk and survival of the germline APOBEC3 deletion polymorphism. The results indicated that the germline deletion is associated with increased glioblastoma multiforme risk and better overall astrocytic glioma survival in the male population of Taiwan. The APOBEC3B deletion homozygote independently predicted better overall survival in male patients with astrocytic glioma, indicating that this hereditary genetic factor has a novel association with glioma risk and is a potential genetic marker for glioma prognosis prediction.
CD34 was quantified in 86 pure low-grade gliomas to identify 1) a histopathological correlate for visible 5-aminolevulinic acid fluorescence and 2) a novel prognostic marker for patient outcome. CD34 microvessel density was significantly higher in tumors showing visible fluorescence. Furthermore, CD34 was a prognostic marker for progression-free survival, malignant transformation-free survival, and overall survival. Thus, visible fluorescence might indicate increased CD34 microvascularity as an early prognostic marker for unfavorable patient outcome in low-grade gliomas.
This study investigated the neuroinflammatory gene expression signature in meningiomas from patients with WHO grade III and grade I meningiomas. Grade I meningiomas were compared with grade I meningiomas that later transformed to grade III meningiomas (premalignant meningiomas) and also with grade III meningiomas. The authors found that genes involved in microglia regulation could distinguish grade I and III meningiomas. Importantly, the authors found that premalignant meningiomas had changes in gene expression years before phenotypic transformation.
The purpose of this study was to describe the biological characteristics of supratentorial meningiomas using tumor volume growth rate as an indicator of growth degree. The combination of known risk factors for growth (age, gender, and MRI signal intensity) allowed the authors to stratify growth rates and generate predictive maps of tumor volume. The results of these analyses may be used as a reference for deciding whether and when to intervene in the treatment of meningiomas.
Immune checkpoint inhibitors (ICIs) and stereotactic radiosurgery (SRS) are commonly utilized in the management of brain metastases. Treatment-related imaging changes (TRICs) are a frequently observed clinical manifestation and are commonly classified as imaging-defined radiation necrosis. However, these findings are not well characterized and may predict a response to SRS and ICIs. The objective of this study was to investigate predictors of TRICs and their impact on patient survival.
This retrospective multicenter cohort study was conducted through the International Radiosurgery Research Foundation. Member institutions submitted de-identified clinical and dosimetric data for patients with non–small cell lung cancer (NSCLC), melanoma, and renal cell carcinoma (RCC) brain metastases that had been treated with SRS and ICIs. Data were collected from March 2020 to February 2021. Univariable and multivariable Cox and logistic regression analyses were performed. The Kaplan-Meier method was used to evaluate overall survival (OS). The diagnosis-specific graded prognostic assessment was used to guide variable selection. TRICs were determined on the basis of MRI, PET/CT, or MR spectroscopy, and consensus by local clinical providers was required.
The analysis included 697 patients with 4536 brain metastases across 11 international institutions in 4 countries. The median follow-up after SRS was 13.6 months. The median age was 66 years (IQR 58–73 years), 54.1% of patients were male, and 57.3%, 36.3%, and 6.4% of tumors were NSCLC, melanoma, and RCC, respectively. All patients had undergone single-fraction radiosurgery to a median margin dose of 20 Gy (IQR 18–20 Gy). TRICs were observed in 9.8% of patients. The median OS for all patients was 24.5 months. On univariable analysis, Karnofsky Performance Status (KPS; HR 0.98, p < 0.001), TRICs (HR 0.67, p = 0.03), female sex (HR 0.67, p < 0.001), and prior resection (HR 0.60, p = 0.03) were associated with improved OS. On multivariable analysis, KPS (HR 0.98, p < 0.001) and TRICs (HR 0.66, p = 0.03) were associated with improved OS. A brain volume receiving ≥ 12 Gy of radiation (V12Gy) ≥ 10 cm3 (OR 2.78, p < 0.001), prior whole-brain radiation therapy (OR 3.46, p = 0.006), and RCC histology (OR 3.10, p = 0.01) were associated with an increased probability of developing TRICs. The median OS rates in patients with and without TRICs were 29.0 and 23.1 months, respectively (p = 0.03, log-rank test).
TRICs following ICI and SRS were associated with a median OS benefit of approximately 6 months in this retrospective multicenter study. Further prospective study and additional stratification are needed to validate these findings and further elucidate the role and etiology of this common clinical scenario.
TO THE EDITOR: I read with interest the article by Nozaki et al.1 (Nozaki T, Sugiyama K, Asakawa T, et al. Increased anteroventral striatal dopamine transporter and motor recovery after subthalamic deep brain stimulation in Parkinson’s disease. J Neurosurg. 2022;137:468-478). The authors examined the striatal dopamine transporter levels before and after subthalamic nucleus deep brain stimulation (STN-DBS) by using PET with [11C]2β-carbomethoxy-3β-(4-fluorophenyl)tropane ([11C]CFT). They found that STN-DBS is associated with an increase in dopamine transporter levels in the anteroventral striatum, which is correlated with the motor recovery after surgery. These
TO THE EDITOR: We read with great interest the article by Di et al.1 (Di L, Shah AH, Mahavadi A, et al. Radical supramaximal resection for newly diagnosed left-sided eloquent glioblastoma: safety and improved survival over gross-total resection. J Neurosurg. Published online May 27, 2022. doi:10.3171/2022.3.JNS212399), in which the authors report their finding that patients with newly diagnosed glioblastoma (GBM) in left-sided eloquent cortex who underwent supramaximal resection (SMR) had better overall survival (OS) and progression-free survival (PFS) than patients who underwent gross-total resection (GTR), as well as comparable postoperative complication rates and Karnofsky
The authors aimed to delineate the course and relationships of the auditory radiations (ARs) from a surgical viewpoint. The ARs could be appreciated as a distinct bundle ascending between the fibers of the sublenticular internal capsule. The ARs traversed superiorly along the roof of the temporal horn by spanning between the optic radiations. The study suggests potential disruption of the ARs' integrity during transsylvian and transtemporal approaches toward the mesial temporal lobe.
The authors developed a new 4-point plasticity grading scale to assess the degree of volitional control achieved after nerve transfer in a brachial plexus injury (BPI) and sought to identify clinical correlations with this score. An important finding of this study, to the authors' knowledge a first attempt to clinically quantify brain plasticity in BPI, was that only approximately 20% of the BPI patients developed complete independent control over the reinnervated muscle, indicating that brain plasticity underlies these changes, but is limited.
The sudden increase in the number of patients requiring intensive care monitoring due to the outbreak of COVID-19 has resulted in postponement of elective procedures of brain tumor patients that traditionally require postoperative surveillance on intensive care units (ICUs). The objective of this study was to identify patients who absolutely require postoperative monitoring. The authors developed a score to predict the incidence of early postoperative complications after brain tumor surgery, helping to stratify the necessity for postoperative monitoring and thus reducing the pressure hospitals face as a result of the lack of ICU capacities.
The authors identified heparin sulfate proteoglycan as a potential binding target for glioblastoma extracellular vesicles (EVs) on healthy monocytes. Treatment of monocytes with heparin reduced EV binding and induction of immunosuppressive changes. This is proof of principle that targeting glioblastoma EV binding can disrupt their protumor effects.
ZEB1, a transcription factor associated with epithelial-mesenchymal transition and central to the stemness of glioblastoma, was studied for its potential role in resistance to chemoradiation. The resistance to therapy was explored in the context of ZEB1 loss and overexpression in glioma stem cells and in patient data. Our results indicate that ZEB1 loss in cancer stem cells confers resistance to chemoradiation and uncovers a potentially targetable cell surface receptor in these resistant cells.
The objective of this study was to describe the authors’ methods for diagnosis, surgical technique, intraoperative findings, and outcomes in consecutive patients undergoing dorsal scapular nerve (DSN) decompression. Patients undergoing DSN decompression showed significant improvements in periscapular pain and disability at 6 and 12 months postoperatively. These study results bring attention to an underrecognized cause of periscapular pain: dorsal scapular neuropathy. Good outcomes were achieved using the reported diagnostic and treatment algorithm.
The authors set out to understand the importance of the proximity of deep brain stimulator contacts to the anterior thalamic nucleus–mammillothalamic tract (ANT-MMT) junction in determining the efficacy of deep brain stimulation in drug-resistant epilepsy. The researchers demonstrated that the accuracy in targeting this area is key in determining a positive clinical outcome. This study provides evidence that the ANT–MMT junction can be targeted for deep brain stimulator implantation in treating epilepsy.
The authors conducted a survey of individuals graduating from Committee on Advanced Subspecialty Training (CAST)–accredited fellowships in the past 5 years to characterize their experiences with and perspectives on the fellowship application process. Respondents agreed that a more standardized application timeline would be beneficial and indicated that postgraduate year (PGY) 5 or PGY6 was the appropriate time to interview for a fellowship. This study emphasizes improvements for the fellowship application process in neurosurgery.
We congratulate the authors for their careful assessment of the impact of their night float system on both the surgical volumes and call burden of residents at various stages of their residency (junior, senior, and chief residents). During residency, which covered multiple hospitals, use of the night float system resulted in a decrease in the number of call days for senior residents and led to a greater number of cases performed by senior residents (although not significantly if normalized for the increased total volume of cases of the program). Based on these results, the authors advocated for the
Researchers evaluated whether embolization before stereotactic radiosurgery was a negative factor for nidus obliteration in patients with brain arteriovenous malformations by equalizing basic characteristics with propensity score matching. Although embolization before stereotactic radiosurgery has been considered as a negative factor of nidus obliteration, it was not significantly associated with a low nidus obliteration rate after equalizing basic characteristics, including the original nidus volume before embolization.
In this report, the authors developed and evaluated the feasibility of resecting the temporal pole and mesial temporal structures through an endoscopic anterior transmaxillary (eATM) approach. This approach provides direct access to these structures, permitting selective resection without transgression of cerebral and potentially eloquent structures such as the temporal stem and lateral temporal neocortex. The eATM approach was successfully used in 4 patients with mesial temporal lobe epilepsy and all achieved Engel class Ia seizure freedom at 1-year follow-up or greater. This study demonstrates the safety and efficacy of the eATM procedure in carefully selected epilepsy patients.
Researchers wanted to understand the effect of implementing a night float system on resident operative experience. Transitioning to a night float call system at their institution increased overall resident operative cases, particularly for the lead resident surgeon. Based on the results of this study, the authors support the use of a night float call system, in certain situations, to consolidate night call, which increases junior resident–level educational opportunities and senior resident cases.
Long-term outcomes after resection of hemorrhagic brainstem cavernous malformations (BSCMs) were evaluated retrospectively in 46 consecutive cases. At last follow-up (median 153 months), the modified Rankin Scale score of 0–2 was noted in 91% and a score of 0 in 39% of patients, and only a lower Lawton grade carried a statistically significant independent association with favorable long-term outcome. These results reconfirm the safety and efficacy of hemorrhagic BSCM resection and independently validate the Lawton grading system.
Because patients occasionally receive potentially disturbing MRI reports suggesting posttreatment progression, the authors investigated the long-term vestibular schwannoma (VS) volume response to Gamma Knife stereotactic radiosurgery (GKRS). The percentage VS volume change measured with precise contouring software in 201 consecutive patients at 18-60 months after GKRS demonstrated that transient tumor volume enlargement (> 20%) in up to 38% of patients did not predict the need for additional treatment, with additional management required in only 5 patients (2.5%). VS patients and their referring doctors can feel reassured that > 95% of patients have long-term tumor control despite MRI reports suggesting transient "progression" after radiosurgery.