Search Results

You are looking at 1 - 8 of 8 items for :

  • Author or Editor: Roukoz B. Chamoun x
  • Journal of Neurosurgery x
  • Refine by Access: all x
Clear All Modify Search
Full access

Neuroendoscopic fenestration of glioependymal cysts to the ventricle: report of 3 cases

Anthony M. Alvarado, Kyle A. Smith, and Roukoz B. Chamoun

Glioependymal cysts are rare congenital lesions of the central nervous system. Reported surgical treatments of these lesions have varied and yielded mixed results, and the optimal surgical strategy is still controversial. The authors here report the clinical and surgical outcomes for three adult patients successfully treated with neuroendoscopic fenestration into the ventricular system. The patients had presented with symptomatic glioependymal cysts in the period from 2013 to 2016 at the authors’ institution. All underwent minimally invasive neuroendoscopic fenestration of the glioependymal cyst into the lateral ventricle via a stereotactically guided burr hole. Presenting clinical and radiological findings, operative courses, and postintervention outcomes were evaluated.

All three patients initially presented with symptoms related to regional mass effect of the underlying glioependymal cyst, including headaches, visual disturbances, and hemiparesis. All patients were successfully treated with endoscopic fenestration of the cyst wall into the lateral ventricle, where the wall was thinnest. Postoperatively, all patients reported improvement in their presenting symptoms, and neuroimaging demonstrated decompression of the cyst. Clinical follow-up ranged from 4 months to 5 years without evidence of reexpansion of the cyst or shunt requirement.

Compared to open resection and shunting of the cyst contents, minimally invasive endoscopic fenestration of a glioependymal cyst into the ventricular system is a safe and effective surgical option. This approach is practical, is less invasive than open resection, and appears to provide a long-term solution.

Restricted access

Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation

Clinical article

Roukoz B. Chamoun, Claudia S. Robertson, and Shankar P. Gopinath

Object

A Glasgow Coma Scale (GCS) score of 3 on presentation in patients with severe traumatic brain injury due to blunt trauma has been recognized as a bad prognostic factor. The reported mortality rate in these patients is very high, even approaching 100% in the presence of fixed and dilated pupils in some series. Consequently, there is often a tendency to treat these patients less aggressively because of the low expectations for a good recovery. In this paper, the authors' purpose is to report their experience in the management of this patient population, analyzing the mortality rate, prognostic factors, and functional outcome of survivors.

Methods

The authors performed a retrospective review of patients who presented between 1997 and 2007 with blunt head trauma and a GCS score of 3. Demographics, mechanism of injury, examination, blood alcohol level, associated injury, intracranial pressure (ICP), surgical procedures, and outcome were all recorded.

Results

A total of 189 patients met the inclusion criteria and were included in this study. The overall mortality rate was 49.2%. At the 6-month follow-up, 13.2% of the entire series achieved a good functional outcome (Glasgow Outcome Scale [GOS] score of 1 or 2).

The patient population was then divided into 2 groups: Group 1 (patients who survived [96]) and Group 2 (patients who died [93]). Patients in Group 1 were younger (mean 33.3 ± 12.8 vs 40.3 ± 16.97 years; p = 0.002) and had lower ICP on admission (mean 16.3 ± 11.1 vs 25.7 ± 12.7 mm Hg; p < 0.001) than those in Group 2. The difference between the 2 groups regarding sex, mechanism of injury, hypotension on admission, alcohol, surgery, and associated injuries was not statistically significant.

The presence of bilateral fixed, dilated pupils was found to be associated with the highest mortality rate (79.7%). Although not statistically significant because of the sample size, pupil status was also a good predictor of the functional outcome at the 6-month follow-up; a good functional outcome (GOS Score 1 or 2) was achieved in 25.5% of patients presenting with bilateral reactive pupils, and 27.6% of patients presenting with a unilateral fixed, dilated pupil, compared with 7.5% for those presenting with bilateral fixed, nondilated pupils, and 1.4% for patients with bilateral fixed, dilated pupils.

Conclusions

Overall, 50.8% of patients survived their injury and 13.2% achieved a good functional outcome after at 6 months of follow-up (GOS Score 1 or 2). Age, ICP on admission, and pupil status were found to be significant predictive factors of outcome. In particular, pupil size and reactivity appeared to be the most important prognostic factor since the mortality rate was 23.5% in the presence of bilateral reactive pupils and 79.7% in the case of bilateral fixed, dilated pupils. The authors believe that patients having suffered traumatic brain injury and present with a GCS score of 3 should still be treated aggressively initially since a good functional outcome can be obtained in some cases.

Restricted access

Spontaneous involution of Rathke cleft cysts: is it rare or just underreported?

Report of 9 cases

Hassan H. Amhaz, Roukoz B. Chamoun, Steven G. Waguespack, Komal Shah, and Ian E. McCutcheon

Rathke cleft cysts (RCCs) are benign cystic lesions of the sella that arise from the remnants of Rathke pouch. Although most are asymptomatic, symptoms can result from mass effect and commonly include headache, endocrinopathy, or visual field disturbance. Although asymptomatic patients undergo conservative treatment, patients with symptoms are typically treated surgically. The authors report 9 patients with symptomatic cystic sellar lesions and imaging characteristics consistent with an RCC; in all cases there was spontaneous involution of the lesions, and in 5 of 7 patients presenting with headache the symptom resolved. Spontaneous involution of an RCC may be more common than the paucity of prior reports would suggest, especially because the natural history of both symptomatic and asymptomatic RCCs is poorly understood. The potential for spontaneous involution, together with the clinical course of the patients reported here, supports a conservative approach for patients with symptomatic RCCs presenting solely with headache.

Restricted access

Meningioma consistency prediction utilizing tumor to cerebellar peduncle intensity on T2-weighted magnetic resonance imaging sequences: TCTI ratio

Kyle A. Smith, John D. Leever, Phillip D. Hylton, Paul J. Camarata, and Roukoz B. Chamoun

OBJECTIVE

Meningioma consistency, firmness or softness as it relates to resectability, affects the difficulty of surgery and, to some degree, the extent of resection. Preoperative knowledge of tumor consistency would affect preoperative planning and instrumentation. Several methods of prediction have been proposed, but the majority lack objectivity and reproducibility or generalizability to other surgeons. In a previous pilot study of 20 patients the authors proposed a new method of prediction based on tumor/cerebellar peduncle T2-weighted imaging intensity (TCTI) ratios in comparison with objective intraoperative findings. In the present study they sought validation of this method.

METHODS

Magnetic resonance images from 100 consecutive patients undergoing craniotomy for meningioma resection were evaluated preoperatively. During surgery a consistency grade was prospectively applied to lesions by the operating surgeon, as determined by suction and/or cavitron ultrasonic surgical aspirator (CUSA) intensity. Consistency grades were A, soft; B, intermediate; and C, fibrous. Using T2-weighted MRI sequences, TCTI ratios were calculated. Analysis of the TCTI ratios and intraoperative tumor consistency was completed with ANOVA and receiver operating characteristic curves.

RESULTS

Of the 100 tumors evaluated, 50 were classified as soft, 29 as intermediate, and 21 as firm. The median TCTI ratio for firm tumors was 0.88; for intermediate tumors, 1.5; and for soft tumors, 1.84. One-way ANOVA comparing TCTI ratios for these groups was statistically significant (p < 0.0001). A single cutoff TCTI value of 1.41 for soft versus firm tumors was found to be 81.9% sensitive and 84.8% specific.

CONCLUSIONS

The authors propose this T2-based method of tumor consistency prediction with correlation to objective intraoperative consistency. This method is quantifiable and reproducible, which expands its usability. Additionally, it places tumor consistency on a graded continuum in a clinically meaningful way that could affect preoperative surgical planning.

Restricted access

Predictors of outcome in civilians with gunshot wounds to the head upon presentation

Clinical article

Loyola V. Gressot, Roukoz B. Chamoun, Akash J. Patel, Alex B. Valadka, Dima Suki, Claudia S. Robertson, and Shankar P. Gopinath

Object

Prediction of outcome from initial presentation after a gunshot wound to the head (GSWH) is essential to further clinical decision making. The authors' goals are to report the survival and functional outcomes of these patients, to identify prognostic factors, and to propose a scoring system that can predict their outcome.

Methods

The records of 199 patients admitted with a GSWH with dural penetration between 1990 and 2008 were retrospectively reviewed. The inclusion criterion was a CT scan available for review. Patients declared brain dead on presentation were excluded, which yielded a series of 119 patients. Statistical analysis was performed using a logistic regression model.

Results

Fifty-eight (49%) of the 119 patients died. Twenty-three patients (19%) had a favorable outcome defined as a 6-month Glasgow Outcome Scale (GOS) score of moderate disability or good recovery, 35 (29%) had a poor outcome (GOS of persistent vegetative state or severe disability), and 3 (3%) were lost to follow-up. Significant prognostic factors for mortality were age older than 35 years, nonreactive pupils, bullet trajectory of bihemispheric (excluding bifrontal), and posterior fossa involvement compared with unihemispheric and bifrontal. Factors that were moderately associated with higher mortality included intracranial pressure (ICP) above 20 mm Hg and Glasgow Coma Scale (GCS) score at presentation of 3 or 4. Upon multivariate analysis, the significant factors for mortality were bullet trajectory and pupillary response. Variables found to be significant for good functional outcome were admission GCS score greater than or equal to 5, pupillary reactivity, and bullet trajectory of unihemispheric or bifrontal. Factors moderately associated with good outcome included age of 35 years or younger, initial ICP 20 mm Hg or lower, and lack of transventricular trajectory. In the multivariate analysis, significant factors for good functional outcome were bullet trajectory and pupillary response, with age moderately associated with improved functional outcomes. The authors also propose a scoring system to estimate survival and functional outcome.

Conclusions

Age, pupils, GCS score, and bullet trajectory on CT scan can be used to determine likelihood of survival and good functional outcome. The authors advocate assessing patients based on these parameters rather than pronouncing a poor prognosis and withholding aggressive resuscitation based upon low GCS score alone.

Free access

Laser ablation after stereotactic radiosurgery: a multicenter prospective study in patients with metastatic brain tumors and radiation necrosis

Manmeet Ahluwalia, Gene H. Barnett, Di Deng, Stephen B. Tatter, Adrian W. Laxton, Alireza M. Mohammadi, Eric Leuthardt, Roukoz Chamoun, Kevin Judy, Anthony Asher, Marco Essig, Jorg Dietrich, and Veronica L. Chiang

OBJECTIVE

Laser Ablation After Stereotactic Radiosurgery (LAASR) is a multicenter prospective study of laser interstitial thermal (LITT) ablation in patients with radiographic progression after stereotactic radiosurgery for brain metastases.

METHODS

Patients with a Karnofsky Performance Scale (KPS) score ≥ 60, an age > 18 years, and surgical eligibility were included in this study. The primary outcome was local progression-free survival (PFS) assessed using the Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) criteria. Secondary outcomes were overall survival (OS), procedure safety, neurocognitive function, and quality of life.

RESULTS

Forty-two patients—19 with biopsy-proven radiation necrosis, 20 with recurrent tumor, and 3 with no diagnosis—were enrolled. The median age was 60 years, 64% of the subjects were female, and the median baseline KPS score was 85. Mean lesion volume was 6.4 cm3 (range 0.4–38.6 cm3). There was no significant difference in length of stay between the recurrent tumor and radiation necrosis patients (median 2.3 vs 1.7 days, respectively). Progression-free survival and OS rates were 74% (20/27) and 72%, respectively, at 26 weeks. Thirty percent of subjects were able to stop or reduce steroid usage by 12 weeks after surgery. Median KPS score, quality of life, and neurocognitive results did not change significantly for either group over the duration of survival. Adverse events were also similar for the two groups, with no significant difference in the overall event rate. There was a 12-week PFS and OS advantage for the radiation necrosis patients compared with the recurrent tumor or tumor progression patients.

CONCLUSIONS

In this study, in which enrolled patients had few alternative options for salvage treatment, LITT ablation stabilized the KPS score, preserved quality of life and cognition, had a steroid-sparing effect, and was performed safely in the majority of cases.

Clinical trial registration no.: NCT01651078 (clinicaltrials.gov)

Free access

5-Aminolevulinic acid for enhanced surgical visualization of high-grade gliomas: a prospective, multicenter study

Alexander J. Schupper, Rebecca B. Baron, William Cheung, Jessica Rodriguez, Steven N. Kalkanis, Muhammad O. Chohan, Bruce J. Andersen, Roukoz Chamoun, Brian V. Nahed, Brad E. Zacharia, Jerone Kennedy, Hugh D. Moulding, Lloyd Zucker, Michael R. Chicoine, Jeffrey J. Olson, Randy L. Jensen, Jonathan H. Sherman, Xiangnan Zhang, Gabrielle Price, Mary Fowkes, Isabelle M. Germano, Bob S. Carter, Constantinos G. Hadjipanayis, and Raymund L. Yong

OBJECTIVE

Greater extent of resection (EOR) is associated with longer overall survival in patients with high-grade gliomas (HGGs). 5-Aminolevulinic acid (5-ALA) can increase EOR by improving intraoperative visualization of contrast-enhancing tumor during fluorescence-guided surgery (FGS). When administered orally, 5-ALA is converted by glioma cells into protoporphyrin IX (PPIX), which fluoresces under blue 400-nm light. 5-ALA has been available for use in Europe since 2010, but only recently gained FDA approval as an intraoperative imaging agent for HGG tissue. In this first-ever, to the authors’ knowledge, multicenter 5-ALA FGS study conducted in the United States, the primary objectives were the following: 1) assess the diagnostic accuracy of 5-ALA–induced PPIX fluorescence for HGG histopathology across diverse centers and surgeons; and 2) assess the safety profile of 5-ALA FGS, with particular attention to neurological morbidity.

METHODS

This single-arm, multicenter, prospective study included adults aged 18–80 years with Karnofsky Performance Status (KPS) score > 60 and an MRI diagnosis of suspected new or recurrent resectable HGG. Intraoperatively, 3–5 samples per tumor were taken and their fluorescence status was recorded by the surgeon. Specimens were submitted for histopathological analysis. Patients were followed for 6 weeks postoperatively for adverse events, changes in the neurological exam, and KPS score. Multivariate analyses were performed of the outcomes of KPS decline, EOR, and residual enhancing tumor volume to identify predictive patient and intraoperative variables.

RESULTS

Sixty-nine patients underwent 5-ALA FGS, providing 275 tumor samples for analysis. PPIX fluorescence had a sensitivity of 96.5%, specificity of 29.4%, positive predictive value (PPV) for HGG histopathology of 95.4%, and diagnostic accuracy of 92.4%. Drug-related adverse events occurred at a rate of 22%. Serious adverse events due to intraoperative neurological injury, which may have resulted from FGS, occurred at a rate of 4.3%. There were 2 deaths unrelated to FGS. Compared to preoperative KPS scores, postoperative KPS scores were significantly lower at 48 hours and 2 weeks but were not different at 6 weeks postoperatively. Complete resection of enhancing tumor occurred in 51.9% of patients. Smaller preoperative tumor volume and use of intraoperative MRI predicted lower residual tumor volume.

CONCLUSIONS

PPIX fluorescence, as judged by the surgeon, has a high sensitivity and PPV for HGG. 5-ALA was well tolerated in terms of drug-related adverse events, and its application by trained surgeons in FGS for HGGs was not associated with any excess neurological morbidity.

Restricted access

2017 AANS Annual Scientific Meeting Los Angeles, CA • April 22–26, 2017