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Justin R. Mascitelli, Michael T. Lawton, Benjamin K. Hendricks, Trevor A. Hardigan, James S. Yoon, Kurt A. Yaeger, Christopher P. Kellner, Reade A. De Leacy, Johanna T. Fifi, Joshua B. Bederson, Felipe C. Albuquerque, Andrew F. Ducruet, Lee A. Birnbaum, Jean Louis R. Caron, Pavel Rodriguez, and J Mocco

OBJECTIVE

Randomized controlled trials have demonstrated the superiority of endovascular therapy (EVT) compared to microsurgery (MS) for ruptured aneurysms suitable for treatment or when therapy is broadly offered to all presenting aneurysms; however, wide neck aneurysms (WNAs) are a challenging subset that require more advanced techniques and warrant further investigation. Herein, the authors sought to investigate a prospective, multicenter WNA registry using rigorous outcome assessments and compare EVT and MS using propensity score analysis (PSA).

METHODS

Untreated, ruptured, saccular WNAs were included in the analysis. A WNA was defined as having a neck ≥ 4 mm or a dome/neck ratio (DNR) < 2. The primary outcome was the modified Rankin Scale (mRS) score at 1 year posttreatment, as assessed by blinded research nurses (good outcome: mRS scores 0–2) and compared using PSA.

RESULTS

The analysis included 87 ruptured aneurysms: 55 in the EVT cohort and 32 in the MS cohort. Demographics were similar in the two cohorts, including Hunt and Hess grade (p = 0.144) and modified Fisher grade (p = 0.475). WNA type inclusion criteria were similar in the two cohorts, with the most common type having a DNR < 2 (EVT 60.0% vs MS 62.5%). More anterior communicating artery aneurysms (27.3% vs 18.8%) and posterior circulation aneurysms (18.2% vs 0.0%) were treated with EVT, whereas more middle cerebral artery aneurysms were treated with MS (34.4% vs 18.2%, p = 0.025). Within the EVT cohort, 43.6% underwent stand-alone coiling, 50.9% balloon-assisted coiling, 3.6% stent-assisted coiling, and 1.8% flow diversion. The 1-year mRS score was assessed in 81 patients (93.1%), and the primary outcome demonstrated no increased risk for a poor outcome with MS compared to EVT (OR 0.43, 95% CI 0.13–1.45, p = 0.177). The durability of MS was higher, as evidenced by retreatment rates of 12.7% and 0% for EVT and MS, respectively (p = 0.04).

CONCLUSIONS

EVT and MS had similar clinical outcomes at 1 year following ruptured WNA treatment. Because of their challenging anatomy, WNAs may represent a population in which EVT’s previously demonstrated superiority for ruptured aneurysm treatment is less relevant. Further investigation into the treatment of ruptured WNAs is warranted.

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Edoardo Agosti, Francesco Doglietto, and Marco M. Fontanella

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Edoardo Agosti, Francesco Doglietto, and Marco M. Fontanella

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Roxanna M. Garcia, Taemin Oh, Tyler S. Cole, Benjamin K. Hendricks, and Michael T. Lawton

OBJECTIVE

Proximity of brainstem cavernous malformations (BSCMs) to tracts and cranial nerve nuclei make it costly to transgress normal tissue in accessing the lesion or disrupting normal tissue adjacent to the lesion in the separation plane. This interplay between tissue sensitivity and extreme eloquence makes it difficult to avoid leaving a remnant on occasion. Recurrences require operative intervention, which may increase morbidity, lengthen recovery, and add to overall costs. An approximately 20-year experience with patients with recurrent BSCM lesions following primary microsurgical resection was reviewed.

METHODS

A prospectively maintained database of 802 patients who underwent microsurgical resection of cerebral cavernous malformations during 1997–2018 was queried to identify 213 patients with BSCMs. A retrospective chart review was conducted for patients with recurrent BSCM after primary resection who required a second surgery.

RESULTS

Fourteen of 213 patients (6.6%) underwent repeat resection for recurrent BSCM. Thirty-four hemorrhagic events were observed among these 14 patients over 576 patient-years (recurrent hemorrhage rate, 5.9% per year; median discrete hemorrhagic events, 2; median time to rehemorrhage, 897 days). BSCM occurred in the pons in 10 cases, midbrain in 2 cases, and medulla in 2 cases. A blind spot in the operative corridor was the most common cause of residual BSCM (9 patients). All recurrent BSCMs were removed completely, although 2 patients each required 2 operations to treat recurrence. Twelve patients had unchanged or improved modified Rankin Scale scores at last clinical evaluation compared with admission, and 2 patients had worse scores. Recurrence was more common among patients who were operated on in the first versus the second half of the series (8.5% vs 4.7%).

CONCLUSIONS

The 6.6% rate of BSCM recurrence requiring reoperation reflects the fine lines between complete resection and recurrence and between safe and harmful surgery. The detection of remnants is difficult postoperatively and remains so even at 6 months when the resection bed has healed. The 5.9% annual hemorrhage risk associated with recurrent BSCM in this experience is consistent with that reported for unoperated BSCMs. The right-angle method helps to anticipate blind spots and meticulously inspect the resection cavity for residual BSCM during surgery. A low percentage of recurrent BSCM (5%–10%) ensures ongoing effort toward an acceptable balance of safety and completeness.

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Colin J. Przybylowski, Benjamin K. Hendricks, Fabio A. Frisoli, Xiaochun Zhao, Claudio Cavallo, Leandro Borba Moreira, Sirin Gandhi, Nader Sanai, Kaith K. Almefty, Michael T. Lawton, and Andrew S. Little

OBJECTIVE

Recently, the prognostic value of the Simpson resection grading scale has been called into question for modern meningioma surgery. In this study, the authors analyzed the relationship between Simpson resection grade and meningioma recurrence in their institutional experience.

METHODS

This study is a retrospective review of all patients who underwent resection of a WHO grade I intracranial meningioma at the authors’ institution from 2007 to 2017. Binary logistic regression analysis was used to assess for predictors of Simpson grade IV resection and postoperative neurological morbidity. Cox multivariate analysis was used to assess for predictors of tumor recurrence. Kaplan-Meier analysis and log-rank tests were used to assess and compare recurrence-free survival (RFS) of Simpson resection grades, respectively.

RESULTS

A total of 492 patients with evaluable data were included for analysis, including 394 women (80.1%) and 98 men (19.9%) with a mean (SD) age of 58.7 (12.8) years. The tumors were most commonly located at the skull base (n = 302; 61.4%) or the convexity/parasagittal region (n = 139; 28.3%). The median (IQR) tumor volume was 6.8 (14.3) cm3. Simpson grade I, II, III, or IV resection was achieved in 105 (21.3%), 155 (31.5%), 52 (10.6%), and 180 (36.6%) patients, respectively. Sixty-three of 180 patients (35.0%) with Simpson grade IV resection were treated with adjuvant radiosurgery. In the multivariate analysis, increasing largest tumor dimension (p < 0.01) and sinus invasion (p < 0.01) predicted Simpson grade IV resection, whereas skull base location predicted neurological morbidity (p = 0.02). Tumor recurrence occurred in 63 patients (12.8%) at a median (IQR) of 36 (40.3) months from surgery. Simpson grade I resection resulted in superior RFS compared with Simpson grade II resection (p = 0.02), Simpson grade III resection (p = 0.01), and Simpson grade IV resection with adjuvant radiosurgery (p = 0.01) or without adjuvant radiosurgery (p < 0.01). In the multivariate analysis, Simpson grade I resection was independently associated with no tumor recurrence (p = 0.04). Simpson grade II and III resections resulted in superior RFS compared with Simpson grade IV resection without adjuvant radiosurgery (p < 0.01) but similar RFS compared with Simpson grade IV resection with adjuvant radiosurgery (p = 0.82). Simpson grade IV resection with adjuvant radiosurgery resulted in superior RFS compared with Simpson grade IV resection without adjuvant radiosurgery (p < 0.01).

CONCLUSIONS

The Simpson resection grading scale continues to hold substantial prognostic value in the modern neurosurgical era. When feasible, Simpson grade I resection should remain the goal of intracranial meningioma surgery. Simpson grade IV resection with adjuvant radiosurgery resulted in similar RFS compared with Simpson grade II and III resections.

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Colin J. Przybylowski, Benjamin K. Hendricks, Fabio A. Frisoli, Xiaochun Zhao, Claudio Cavallo, Leandro Borba Moreira, Sirin Gandhi, Nader Sanai, Kaith K. Almefty, Michael T. Lawton, and Andrew S. Little

OBJECTIVE

Recently, the prognostic value of the Simpson resection grading scale has been called into question for modern meningioma surgery. In this study, the authors analyzed the relationship between Simpson resection grade and meningioma recurrence in their institutional experience.

METHODS

This study is a retrospective review of all patients who underwent resection of a WHO grade I intracranial meningioma at the authors’ institution from 2007 to 2017. Binary logistic regression analysis was used to assess for predictors of Simpson grade IV resection and postoperative neurological morbidity. Cox multivariate analysis was used to assess for predictors of tumor recurrence. Kaplan-Meier analysis and log-rank tests were used to assess and compare recurrence-free survival (RFS) of Simpson resection grades, respectively.

RESULTS

A total of 492 patients with evaluable data were included for analysis, including 394 women (80.1%) and 98 men (19.9%) with a mean (SD) age of 58.7 (12.8) years. The tumors were most commonly located at the skull base (n = 302; 61.4%) or the convexity/parasagittal region (n = 139; 28.3%). The median (IQR) tumor volume was 6.8 (14.3) cm3. Simpson grade I, II, III, or IV resection was achieved in 105 (21.3%), 155 (31.5%), 52 (10.6%), and 180 (36.6%) patients, respectively. Sixty-three of 180 patients (35.0%) with Simpson grade IV resection were treated with adjuvant radiosurgery. In the multivariate analysis, increasing largest tumor dimension (p < 0.01) and sinus invasion (p < 0.01) predicted Simpson grade IV resection, whereas skull base location predicted neurological morbidity (p = 0.02). Tumor recurrence occurred in 63 patients (12.8%) at a median (IQR) of 36 (40.3) months from surgery. Simpson grade I resection resulted in superior RFS compared with Simpson grade II resection (p = 0.02), Simpson grade III resection (p = 0.01), and Simpson grade IV resection with adjuvant radiosurgery (p = 0.01) or without adjuvant radiosurgery (p < 0.01). In the multivariate analysis, Simpson grade I resection was independently associated with no tumor recurrence (p = 0.04). Simpson grade II and III resections resulted in superior RFS compared with Simpson grade IV resection without adjuvant radiosurgery (p < 0.01) but similar RFS compared with Simpson grade IV resection with adjuvant radiosurgery (p = 0.82). Simpson grade IV resection with adjuvant radiosurgery resulted in superior RFS compared with Simpson grade IV resection without adjuvant radiosurgery (p < 0.01).

CONCLUSIONS

The Simpson resection grading scale continues to hold substantial prognostic value in the modern neurosurgical era. When feasible, Simpson grade I resection should remain the goal of intracranial meningioma surgery. Simpson grade IV resection with adjuvant radiosurgery resulted in similar RFS compared with Simpson grade II and III resections.

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Benjamin K. Hendricks, James S. Yoon, Kurt Yaeger, Christopher P. Kellner, J Mocco, Reade A. De Leacy, Andrew F. Ducruet, Michael T. Lawton, and Justin R. Mascitelli

OBJECTIVE

Wide-necked aneurysms (WNAs) are a variably defined subset of cerebral aneurysms that require more advanced endovascular and microsurgical techniques than those required for narrow-necked aneurysms. The neurosurgical literature includes many definitions of WNAs, and a systematic review has not been performed to identify the most commonly used or optimal definition. The purpose of this systematic review was to highlight the most commonly used definition of WNAs.

METHODS

The authors searched PubMed for the years 1998–2017, using the terms “wide neck aneurysm” and “broad neck aneurysm” to identify relevant articles. All results were screened for having a minimum of 30 patients and for clearly stating a definition of WNA. Reference lists for all articles meeting the inclusion criteria were also screened for eligibility.

RESULTS

The search of the neurosurgical literature identified 809 records, of which 686 were excluded (626 with < 30 patients; 60 for lack of a WNA definition), leaving 123 articles for analysis. Twenty-seven unique definitions were identified and condensed into 14 definitions. The most common definition was neck size ≥ 4 mm or dome-to-neck ratio < 2, which was used in 49 articles (39.8%). The second most commonly used definition was neck size ≥ 4 mm, which was used in 26 articles (21.1%). The rest of the definitions included similar parameters with variable thresholds. There was inconsistent reporting of the precise dome measurements used to determine the dome-to-neck ratio. Digital subtraction angiography was the only imaging modality used to study the aneurysm morphology in 87 of 122 articles (71.3%).

CONCLUSIONS

The literature has great variability regarding the definition of a WNA. The most prevalent definition is a neck diameter of ≥ 4 mm or a dome-to-neck ratio of < 2. Whether this is the most appropriate and clinically useful definition is an area for future study.