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Ju-Hwi Kim, Kyung-Sub Moon, Ji-Ho Jung, Woo-Youl Jang, Tae-Young Jung, In-Young Kim, Kyung-Hwa Lee and Shin Jung

OBJECTIVE

Indocyanine green videoangiography (ICGVA) has been used in many neurosurgical operations, including vascular and brain tumor fields. In this study, the authors applied ICGVA to intracranial meningioma surgery and evaluated it usefulness with attention to collateral venous flow.

METHODS

Forty-two patients with intracranial meningioma who underwent ICGVA during microsurgical resection were retrospectively analyzed. For ICGVA, the ICG was injected intravenously at the standard dose of 12.5 mg before and/or after tumor resection. Intravascular fluorescence from blood vessels was imaged through a microscope with a special filter and infrared excitation light to illuminate the operating field. The authors assessed the benefits of ICGVA and analyzed its findings with preoperative radiological findings on MRI.

RESULTS

ICGVA allowed real-time assessment of the patency and flow direction in very small peritumoral vessels in all cases. A safe dural incision could also be done based on information from ICGVA. The collateral venous channel due to venous obstruction of tumoral compression was found in 10 cases, and venous flow restoration after tumor resection was observed promptly after tumor resection in 4 cases. Peritumoral brain edema (PTBE) was observed on preoperative T2-weighted MRI in 19 patients. The presence of collateral venous circulation or flow restoration was significantly related to PTBE formation in multivariate analysis (p = 0.001; HR 0.027, 95% CI 0.003–0.242).

CONCLUSIONS

ICGVA, an excellent method for monitoring blood flow during meningioma resection, provides valuable information as to the presence of venous collaterals and flow restoration. Furthermore, the fact that the presence of venous collaterals was found to be associated with PTBE may directly support the venous theory as the pathogenesis of PTBE formation.

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Nícollas Nunes Rabelo, Manoel Jacobsen Teixeira and Eberval Gadelha Figueiredo

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Nícollas Nunes Rabelo, Bruno Braga Sisnando da Costa, Gabriel Reis Sakaya, Manoel Jacobsen Teixeira and Eberval Gadelha Figueiredo

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Ryo Kanematsu, Junya Hanakita, Toshiyuki Takahashi, Yosuke Tomita and Manabu Minami

OBJECTIVE

Surgical management of thoracic ossification of the posterior longitudinal ligament (OPLL) remains challenging because of the anatomical complexity of the thoracic spine and the fragility of the thoracic spinal cord. Several surgical approaches have been described, but it remains unclear which of these is the most effective. The present study describes the microsurgical removal of OPLL in the middle thoracic level via the transthoracic anterolateral approach without spinal fusion, including the surgical outcome and operative tips.

METHODS

Between 2002 and 2017, a total of 8 patients with thoracic myelopathy due to OPLL were surgically treated via the transthoracic anterolateral approach without spinal fusion. The surgical techniques are described in detail. Clinical outcome, surgical complications, and the pre- and postoperative thoracic kyphotic angle were assessed.

RESULTS

The mean patient age at the time of surgery was 55 years (range 47–77 years). There were 5 women and 3 men. The surgically treated levels were within T3–9. The clinical symptoms and Japanese Orthopaedic Association (JOA) score improved postoperatively in 7 cases, but did not change in 1 case. The mean JOA score increased from 6.4 preoperatively to 7.5 postoperatively (recovery rate 26%). Intraoperative CSF leakage occurred in 4 cases, and was successfully treated with fibrin glue sealing and spinal drainage. The mean follow-up period was 82.6 months (range 15.3–169 months). None of the patients had deterioration of the thoracic kyphotic angle.

CONCLUSIONS

Anterior decompression is the logical and ideal procedure to treat thoracic myelopathy caused by OPLL on the concave side of the spinal cord; however, this procedure is technically demanding. Microsurgery via the transthoracic anterolateral approach enables direct visualization of the thoracic ventral ossified lesion. The use of microscopic procedures might negate the need for bone grafting or spinal instrumentation.

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Yong-Chan Kim, Ji Hao Cui, Ki-Tack Kim, Gyu-Taek Park, Keun-Ho Lee, Sung-Min Kim and Lawrence G. Lenke

OBJECTIVE

In this study, the authors’ goal was to develop and validate novel radiographic parameters that better describe total body sagittal alignment (TBSA).

METHODS

One hundred sixty-six consecutive operative spinal deformity patients were evaluated using full-body stereoradiographic imaging. Seven TBSA parameters were measured and then correlated to 6 commonly used spinopelvic measurements. TBSA measures consisted of 4 distance measures relating the cranial center of mass (CCOM) to the sacrum, hips, knees, and ankles, and 3 angular measures relating the CCOM to the hips, knees, and ankles. Furthermore, each TBSA parameter was correlated to patient-reported outcome (PRO) scores using the Oswestry Disability Index (ODI) and Scoliosis Research Society–22 (SRS-22) instruments. Thirty patients were randomly selected for inter- and intraobserver reliability testing of the TBSA parameters using intraclass correlation coefficients (ICCs).

RESULTS

All TBSA radiographic parameters demonstrated strong linear correlation with the currently accepted primary measure of sagittal balance, the C7 sagittal vertical axis (r = 0.55–0.96, p < 0.001). Moreover, 5 of 7 TBSA measures correlated strongly with ODI and SRS-22 total scores (r = 0.42–0.51, p < 0.001). Inter- and intraobserver reliability for all TBSA measures was good to excellent (interrater ICC = 0.70–0.98, intrarater ICC = 0.77–1.0).

CONCLUSIONS

In spine deformity patients, novel TBSA radiographic parameters correlated well with PROs and with currently utilized spinal sagittal measurements. Inter- and intrarater reliability was high for these novel parameters. This is the first study to propose a reliable method for measuring head-to-toe global spinal alignment.

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Jaes C. Jones, Jacob A. Miller, Dattanand M. Sudarshana, Nicolas R. Thompson, Edward C. Benzel and Thomas E. Mroz

OBJECTIVE

In 2009, 2 randomized controlled trials demonstrated no improvement in pain following vertebral augmentation compared with sham surgery. However, a recent randomized trial demonstrated significant pain relief in patients following vertebroplasty compared to controls treated with conservative medical management. This study is a retrospective review of prospectively collected patient-reported quality of life (QOL) outcomes. The authors hypothesized that vertebral augmentation procedures offer a QOL benefit, but that this benefit would be diminished in patients with a history of depression and/or in patients undergoing vertebral augmentation at more than 1 level.

METHODS

Multivariable linear regression was used to identify predictors of postoperative pain assessed using the Pain Disability Questionnaire (PDQ), Patient Health Questionnaire 9 (PHQ-9), and EQ-5D scores. Eleven candidate predictors were selected a priori: age, sex, smoking history, coronary artery disease, depression, diabetes, procedure location (thoracic, lumbar), BMI, prior spine surgery, procedure indication (metastases, osteoporosis/osteopenia, other), and number of levels (1, 2, 3, or more).

RESULTS

A total of 143 patients were included in the study. For each 10-year increase in age, postoperative PDQ scores decreased (improved) by 9.7 points (p < 0.001). Patients with osteoporosis/osteopenia had significantly higher (worse) postoperative PDQ scores (+17.97, p = 0.028) than patients with metastatic lesions. Male sex was associated with higher (worse) postoperative PHQ-9 scores (+2.48, p = 0.010). Compared to single-level augmentation, operations at 2 levels were associated with significantly higher PHQ-9 scores (+2.58, p = 0.017). Current smokers had significantly lower PHQ-9 scores (−1.98, p = 0.023) than never smokers. No predictors were associated with significantly different EQ-5D score.

CONCLUSIONS

Variables associated with worse postoperative PDQ scores included younger age and osteoporosis/osteopenia. Variables associated with decreased (better) postoperative PHQ-9 scores included female sex, single operative vertebral level, and positive smoking status (i.e., current smoker). These clinically relevant predictors may permit identification of patients who may benefit from vertebral augmentation.

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Jillian M. Berkman, Jonathan Dallas, Jaims Lim, Ritwik Bhatia, Amber Gaulden, Stephen R. Gannon, Chevis N. Shannon, Adam J. Esbenshade and John C. Wellons III

OBJECTIVE

Little is understood about the role that health disparities play in the treatment and management of brain tumors in children. The purpose of this study was to determine if health disparities impact the timing of initial and follow-up care of patients, as well as overall survival.

METHODS

The authors conducted a retrospective study of pediatric patients (< 18 years of age) previously diagnosed with, and initially treated for, a primary CNS tumor between 2005 and 2012 at Monroe Carell Jr. Children’s Hospital at Vanderbilt. Primary outcomes included time from symptom presentation to initial neurosurgery consultation and percentage of missed follow-up visits for ancillary or core services (defined as no-show visits). Core services were defined as healthcare interactions directly involved with CNS tumor management, whereas ancillary services were appointments that might be related to overall care of the patient but not directly focused on treatment of the tumor. Statistical analysis included Pearson’s chi-square test, nonparametric univariable tests, and multivariable linear regression. Statistical significance was set a priori at p < 0.05.

RESULTS

The analysis included 198 patients. The median time from symptom onset to initial presentation was 30.0 days. A mean of 7.45% of all core visits were missed. When comparing African American and Caucasian patients, there was no significant difference in age at diagnosis, timing of initial symptoms, or tumor grade. African American patients missed significantly more core visits than Caucasian patients (p = 0.007); this became even more significant when controlling for other factors in the multivariable analysis (p < 0.001). African American patients were more likely to have public insurance, while Caucasian patients were more likely to have private insurance (p = 0.025). When evaluating survival, no health disparities were identified.

CONCLUSIONS

No significant health disparities were identified when evaluating the timing of presentation and survival. A racial disparity was noted when evaluating missed follow-up visits. Future work should focus on identifying reasons for differences and whether social determinants of health affect other aspects of treatment.

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Daniel-Alexandre Bisson, Peter Dirks, Afsaneh Amirabadi, Manohar M. Shroff, Timo Krings, Vitor Mendes Pereira and Prakash Muthusami

OBJECTIVE

There are little data in the literature on the characteristics and natural history of unruptured intracranial aneurysms in children. The authors analyzed their experience with unruptured intracranial aneurysms in the pediatric population at their tertiary care pediatric institution over the last 18 years. The first objective was to assess the imaging characteristics and natural history of these aneurysms in order to help guide management strategies in the future. A second objective was to evaluate the frequency of an underlying condition when an incidental intracranial aneurysm was detected in a child.

METHODS

The authors conducted a Research Ethics Board–approved retrospective review of incidental intracranial aneurysms in patients younger than 18 years of age who had been treated at their institution in the period from 1998 to 2016. Clinical (age, sex, syndrome) and radiological (aneurysm location, type, size, thrombus, mass effect) data were recorded. Follow-up imaging was assessed for temporal changes.

RESULTS

Sixty intracranial aneurysms occurred in 51 patients (36 males, 15 females) with a mean age of 10.5 ± 0.5 years (range 9 months–17 years). Forty-five patients (88.2%) had a single aneurysm, while 2 and 3 aneurysms were found in 3 patients each (5.8%). Syndromic association was found in 22 patients (43.1%), most frequently sickle cell disease (10/22 [45.5%]). Aneurysms were saccular in 43 cases (71.7%; mean size 5.0 ± 5.7 mm) and fusiform in the remaining 17 (28.3%; mean size 6.5 ± 2.7 mm). Thirty-one aneurysms (51.7%) arose from the internal carotid artery (right/left 1.4), most commonly in the cavernous segment (10/31 [32.3%]). Mean size change over the entire follow-up of 109 patient-years was a decrease of 0.6 ± 4.2 mm (range −30.0 to +4.0 mm, rate −0.12 ± 9.9 mm/yr). Interval growth (2.0 ± 1.0 mm) was seen in 8 aneurysms (13.3%; 4 saccular, 4 fusiform). An interval decrease in size (8.3 ± 10.7 mm) was seen in 6 aneurysms (10%). There was an inverse relationship between aneurysm size and growth rate (r = −0.82, p < 0.00001). One aneurysm was treated endovascularly with internal carotid artery sacrifice.

CONCLUSIONS

Unruptured pediatric intracranial aneurysms are most frequently single but can occur in multiples in a syndromic setting. None of the cases from the study period showed clinical or imaging signs of rupture. Growth over time, although unusual and slow, can occur in a proportion of these patients, who should be identified for short-term imaging surveillance.

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Yu-Li Lee, Shu-Tian Chen, Jen-Tsung Yang, Hsu-Huei Weng, Hsueh-Lin Wang and Yuan-Hsiung Tsai

OBJECTIVE

Trigeminal neuralgia (TN) is facial pain that is usually caused by neurovascular compression syndrome and is characterized by suddenly intense and paroxysmal pain. Radiofrequency lesioning (RFL) is one of the major treatments for TN, but the treatment response for RFL is sometimes inconsistent, and the recurrence of TN is not uncommon. This study aimed to estimate the outcome predictors of TN treated with RFL by using the parameters of diffusion tensor imaging (DTI).

METHODS

Fifty-one patients with TN who were treated with RFL were enrolled in the study. MRI was performed in all patients within 1 week before surgery. The visual analog scale was used to evaluate symptom severity at three time points: before, 1 week after, and 3 months after RFL. The involved cisternal segment of the trigeminal nerves was manually selected, and the histograms of each of the diffusivity metrics—including the apparent diffusion coefficient (ADC), fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD)—were measured. The differences in the means, as well as the kurtosis and skewness of each of the diffusivity metrics between the nonrecurrent and recurrent groups, were then analyzed using the Mann-Whitney U-test.

RESULTS

There were significantly lower kurtosis values (a broader peak of the distributional curves) for both FA and ADC in the recurrent group (p = 0.0004 and 0.015, respectively), compared to the nonrecurrent group. The kurtoses of AD and RD, as well as the mean and skewness of all other diffusivity metrics, did not show significant differences between the two groups.

CONCLUSIONS

The pretreatment diffusivity metrics of DTI and ADC may be feasible imaging biomarkers for predicting the outcome of TN after RFL. A clarification of the kurtosis value of FA and ADC is helpful for determining the prognosis of patients after RFL.

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Grace F. Donzelli, Jeffrey Nelson, David McCoy, Charles E. McCulloch, Steven W. Hetts, Matthew R. Amans, Christopher F. Dowd, Van V. Halbach, Randall T. Higashida, Michael T. Lawton, Helen Kim and Daniel L. Cooke

OBJECTIVE

Preoperative embolization of brain arteriovenous malformations (AVMs) is performed to facilitate resection, although its impact on surgical performance has not been clearly defined. The authors tested for associations between embolization and surgical performance metrics.

METHODS

The authors analyzed AVM cases resected by one neurosurgeon from 2006 to 2017. They tested whether cases with and without embolization differed from one another with respect to patient and AVM characteristics using t-tests for continuous variables and Fisher’s exact tests for categorical variables. They used simple and multivariable regression models to test whether surgical outcomes (blood loss, resection time, surgical clip usage, and modified Rankin Scale [mRS] score) were associated with embolization. Additional regression analyses integrated the peak arterial afferent contrast normalized for the size of the region of interest (Cmax/ROI) into models as an additional predictor.

RESULTS

The authors included 319 patients, of whom 151 (47%) had preoperative embolization. Embolized AVMs tended to be larger (38% with diameter > 3 cm vs 19%, p = 0.001), less likely to have hemorrhaged (48% vs 63%, p = 0.013), or be diffuse (19% vs 29%, p = 0.045). Embolized AVMs were more likely to have both superficial and deep venous drainage and less likely to have exclusively deep drainage (32% vs 17% and 12% vs 23%, respectively; p = 0.002). In multivariable analysis, embolization was not a significant predictor of blood loss or mRS score changes, but did predict longer operating times (+29 minutes, 95% CI 2–56 minutes; p = 0.034) and increased clip usage (OR 2.61, 95% CI 1.45–4.71; p = 0.001). Cmax/ROI was not a significant predictor, although cases with large Cmax/ROI tended to have longer procedure times (+25 minutes per doubling of Cmax/ROI, 95% CI 0–50 minutes; p = 0.051).

CONCLUSIONS

In this series, preoperative embolization was associated with longer median resection times and had no association with intraoperative blood loss or mRS score changes.