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Anthony O. Asemota and Gary L. Gallia

OBJECTIVE

Frailty, a state of decreased physiological reserve, has been shown to significantly impact outcomes of surgery. The authors sought to examine the impact of frailty on the short-term outcomes of patients undergoing transsphenoidal pituitary surgery.

METHODS

Weighted data from the 2000–2014 National (Nationwide) Inpatient Sample were studied. Patients diagnosed with pituitary tumors or disorders who had undergone transsphenoidal pituitary surgery were identified. Frailty was determined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. Standard descriptive techniques and matched propensity score analyses were used to explore the odds ratios of postoperative complications, discharge dispositions, and costs.

RESULTS

A total of 115,317 cases were included in the analysis. Frailty was present in 1.48% of cases. The mean age of frail versus non-frail patients was 57.14 ± 16.96 years (mean ± standard deviation) versus 51.91 ± 15.88 years, respectively (p < 0.001). A greater proportion of frail compared to non-frail patients had an age ≥ 65 years (37.08% vs 24.08%, respectively, p < 0.001). Frail patients were more likely to be black or Hispanic (p < 0.001), possess Medicare or Medicaid insurance (p < 0.001), belong to lower-median-income groups (p < 0.001), and have greater comorbidity (p < 0.001). Results of propensity score–matched multivariate analysis revealed that frail patients were more likely to develop fluid and electrolyte disorders (OR 1.61, 95% CI 1.07–2.43, p = 0.02), intracranial vascular complications (OR 2.73, 95% CI 1.01–7.49, p = 0.04), mental status changes (OR 3.60, 95% CI 1.65–7.82, p < 0.001), and medical complications including pulmonary insufficiency (OR 2.01, 95% CI 1.13–4.05, p = 0.02) and acute kidney failure (OR 4.70, 95% CI 1.88–11.74, p = 0.01). The mortality rate was higher among frail patients (1.46% vs 0.37%, p < 0.001). Frail patients also demonstrated a greater likelihood for nonroutine discharges (p < 0.001), higher mean total charges ($109,614.33 [95% CI $92,756.09–$126,472.50] vs $56,370.35 [95% CI $55,595.72–$57,144.98], p < 0.001), and longer hospitalizations (9.27 days [95% CI 7.79–10.75] vs 4.46 days [95% CI 4.39–4.53], p < 0.001).

CONCLUSIONS

Frailty in patients undergoing transsphenoidal pituitary surgery is associated with worse postoperative outcomes and higher costs, indicating that state’s potential role in routine preoperative risk stratification.

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Gary L. Gallia and Charles Teo

✓Spontaneous ventriculocisternostomy, the spontaneous communication between the ventricular system and the subarachnoid space, is rare. The authors report a case of an infant with obstructive hydrocephalus who developed a spontaneous third ventriculocisternostomy. The infant was initially evaluated for progressive ventriculomegaly and increasing head circumference (HC). During follow-up, the patient's HC began to follow percentile lines and magnetic resonance (MR) imaging demonstrated a reduction of the hydrocephalus. Flow-sensitive phase-contrast cine MR images revealed cerebrospinal fluid (CSF) flow through the floor of the third ventricle between the tuber cinereum and the mammillary bodies connecting the ventricular system with the prepontine cistern. Although rare, clinicians should be cognizant of this phenomenon as it may eliminate the need for CSF diversion.

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Gary L. Gallia, Carolyn Moore, Lori Jordan, Philippe Gailloud and George I. Jallo

✓Neonatal intracranial aneurysms are rare. The authors report the case of a 4-week-old girl who presented with left-eye ptosis and proptosis. Computerized tomography scanning and magnetic resonance imaging demonstrated a mass involving the left cavernous sinus and middle cranial fossa. Cerebral angiography revealed a large complex left cavernous carotid artery (CA) aneurysm. The patient underwent endovascular treatment in which detachable coils and n-butyl cyanoacrylate glue were used to achieve complete obliteration of the aneurysm. To the authors' knowledge, this is the first reported neonatal intracranial aneurysm originating from the cavernous CA and treated endovascularly. The authors review the literature on neonatal intracranial aneurysms.

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Deric M. Park

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Gary L. Gallia, Daniel M. Sciubba, Ali Bydon, Ian Suk, Jean-Paul Wolinsky, Ziya L. Gokaslan and Timothy F. Witham

✓The authors describe a technique for total L-5 spondylectomy and reconstruction of the lumbosacral junction. The technique, which involves separately staged posterior and anterior procedures, is reported in two patients harboring neoplasms that involved the L-5 level. The first stage consisted of a posterior approach with removal of all posterior bone elements of L-5 and radical L4–5 and L5–S1 discectomies. Lumbosacral and lumbopelvic instrumentation included pedicle screws as well as iliac screws or a transiliac rod. The second stage consisted of an anterior approach with mobilization of vascular structures, completion of L4–5 and L5–S1 discectomies, and removal of the L-5 vertebral body. Anterior lumbosacral reconstruction included placement of a distractable cage and tension band between L-4 and S-1. Allograft bone was used for fusion in both stages. No significant complications were encountered. At more than 1 year of follow-up, both patients were independently ambulatory, without evidence of recurrent or metastatic disease, and adequate lumbosacral alignment was maintained. The authors conclude that this technique can be safely performed in appropriately selected patients with neoplasms involving L-5.

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Wesley Hsu, I-Mei Siu, Gustavo Pradilla, Ziya L. Gokaslan, George I. Jallo and Gary L. Gallia

Object

Advances in the diagnosis and management of patients with spinal cord tumors have been limited because of the rarity of the disease and the limitations of current animal models for spinal cord glioma. The ideal spinal cord tumor model would possess a number of characteristics, including the use of human glioma cells that capture the growth pattern and local invasive nature of their human counterpart. In this study, the authors' goal was to develop a novel spinal cord tumor model using a human neurosphere cell line.

Methods

Eighteen female athymic rats were randomized into 3 experimental groups. Animals in the first group (6 rats) received a 3-ml intramedullary injection containing DMEM and were used as controls. Animals in the second group (6 rats) received a 3-ml intramedullary injection containing 100,000 glioblastoma multiforme (GBM) neurosphere cells in 3 ml DMEM. Animals in the third group (6 rats) received a 3-ml intramedullary injection containing 9L gliosarcoma cells in 3 ml DMEM. Functional testing of hindlimb strength was assessed using the Basso-Beattie-Bresnahan (BBB) scale. Once the functional BBB score of an animal was less than or equal to 5 (slight movement of 2 joints and extensive movement of the third), euthanasia was performed.

Results

Animals in the GBM neurosphere group had a mean survival of 33.3 ± 2.0 days, which was approximately twice as long as animals in the 9L gliosarcoma group (16.3 ± 2.3 days). There was a significant difference between survival of the GBM neurosphere and 9L gliosarcoma groups (p < 0.001). None of the control animals died (p < 0.001 for GBM neurosphere group vs controls and 9L vs controls). Histopathological examination of the rats injected with 9L gliosarcoma revealed that all animals developed highly cellular, well-circumscribed lesions causing compression of the surrounding tissue, with minimal invasion of the surrounding gray and white matter. Histopathological examination of animals injected with GBM neurospheres revealed that all animals developed infiltrative lesions with a high degree of white and gray matter invasion along with areas of necrosis.

Conclusions

The authors have established a novel animal model of spinal cord glioma using neurospheres derived from human GBM. When injected into the spinal cords of athymic nude rats, neurospheres gave rise to infiltrative, actively proliferating tumors that were histologically identical to spinal cord glioma in humans. On the basis of their results, the authors conclude that this is a reproducible animal model of high-grade spinal cord glioma based on a human GBM neurosphere line. This model represents an improvement over other models using nonhuman glioma cell lines. Novel therapeutic strategies can be readily evaluated using this model.

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Vertebral synovial chondromatosis

Report of two cases and review of the literature

Gary L. Gallia, Nirit Weiss, James N. Campbell, Edward F. McCarthy, Anthony P. Tufaro and Ziya L. Gokaslan

✓ Synovial chondromatosis is an uncommon disorder characterized by the formation of multiple cartilaginous nodules within the synovium, most commonly affecting large joints. Its involvement with the spine is rare; only six cases have been reported. The authors describe two patients with synovial chondromatosis involving the cervical spine. In the first case, synovial chondromatosis arose from the left C1–2 facet joint. This patient underwent a two-stage procedure including a posterior approach for tumor resection and occipitocervical fusion as well as a transmandibular circumglossal approach to the anterior craniocervical junction to complete the tumor removal. Interestingly, on histopathological examination, scattered foci of low-grade chondrosarcoma were intermixed within the synovial chondromatosis. To the authors' knowledge, this is the first report of secondary low-grade chondrosarcoma arising in vertebral synovial chondromatosis. In the second case, synovial chondromatosis involved the left C4–5 facet joint. Tumor resection and cervical fusion were performed via a posterior approach.

In this report, the authors describe the clinical presentation, radiographic findings, operative details, histopathological features, and clinicoradiological follow-up data obtained in these two patients and review the literature pertaining to this rare entity.

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Gary L. Gallia, Anthony O. Asemota, Ari M. Blitz, Andrew P. Lane, Wayne Koch, Douglas D. Reh and Masaru Ishii

OBJECTIVE

Olfactory neuroblastoma (ONB) is a rare malignant neoplasm of the sinonasal cavity. Surgery has been and remains a mainstay of treatment for patients with this tumor. Open craniofacial resections have been the treatment of choice for many decades. More recently, experience has been growing with endoscopic approaches in the management of patients with ONB. The object of this study is to report the authors’ experience over the past 11 years with ONB patients treated with purely endonasal endoscopic techniques.

METHODS

The authors performed a retrospective chart review of 20 consecutive patients with ONB who underwent a completely endonasal endoscopic approach for an oncological tumor resection at their institution between January 2006 and January 2017. Patient demographics, tumor stage, pathological grade, frozen section analysis, permanent margin assessment, perioperative complications, postoperative therapy, length of follow-up, and outcomes at last follow-up were collected and analyzed.

RESULTS

Eighteen patients presented with newly diagnosed disease, with a modified Kadish stage of A in 2 cases, B in 3, C in 11, and D in 2. Two patients presented with recurrent tumors. An average of 25.3 specimens per patient were examined by frozen section analysis. Although analysis of intraoperative frozen section margins was negative in all but 1 case, microscopic foci of tumor were found in 7 cases (35%) on permanent histopathological analysis. Perioperative complications occurred in 7 patients (35%) including 1 patient who developed a cerebrospinal fluid leak; there were no episodes of meningitis. All but 1 patient received postoperative radiotherapy, and 5 patients received postoperative chemotherapy. With a mean follow-up of over 5 years, 19 patients were alive and 1 patient died from an unrelated cause. There were 2 cases of tumor recurrence. The 5-year overall, disease-specific, and recurrence-free survival rates were 92.9%, 100%, and 92.9%, respectively.

CONCLUSIONS

The current results provide additional evidence for the continued use of endoscopic procedures in the management of this malignancy.

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Daniel M. Sciubba, Gary L. Gallia, Pablo Recinos, Ira M. Garonzik and Richard E. Clatterbuck

✓ Ionizing radiation therapy is associated with pathological vascular changes in intracranial vessels, most commonly in the form of vessel thrombosis and occlusion. The development of an intracranial aneurysm following such therapy, however, is far less common. In this report the authors describe a 24-year-old man in whom a distal middle cerebral artery aneurysm developed 15 years after radiotherapy, which was given as adjuvant treatment following resection of a medulloblastoma. The patient underwent a craniotomy for microsurgical trapping of the aneurysm and was discharged without any neurological deficit. This case serves to remind clinicians of the possibility, albeit rare, that intracranial aneurysms may form following cranial radiotherapy.

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Daryl R. Fourney, Laurence D. Rhines, Stephen J. Hentschel, John M. Skibber, Jean-Paul Wolinsky, Kristin L. Weber, Dima Suki, Gary L. Gallia, Ira Garonzik and Ziya L. Gokaslan

Object

En bloc resection with adequate margins is associated with the highest probability of long-term tumor control or cure in most cases of primary sacral malignancies. The authors present their experience with a systematic approach to these lesions. They provide a novel classification of surgical techniques based on the level of nerve root sacrifice and evaluate the functional and oncological outcomes.

Methods

Seventy-eight consecutive patients underwent 94 resections of sacral neoplasms at The University of Texas M. D. Anderson Cancer Center in Houston between August 1993 and June 2002. The records of 29 consecutive patients who underwent en bloc resection of primary sacral tumors were retrospectively reviewed. The median follow-up period was 55 months (range 1–103 months). Chordoma was the most frequent tumor type (16 cases). Midline sacral amputation was performed in 25 patients (eight low, four middle, seven high, and five total sacrectomies; one hemicorporectomy). Lateral sacrectomy was undertaken in four patients (two unilateral excisions of the sacroiliac joint and two hemisacrectomies). The surgical margins were wide in 19 cases, marginal in nine, and contaminated in one. The type of sacrectomy correlated with characteristic outcomes with respect to bladder, bowel, and ambulatory functions. Duration of hospital stay was related to the extent of sacrectomy (p = 0.003, Wilcoxon signed-rank test). The median Kaplan—Meier disease-free survival for patients with chordoma was 68 months (95% confidence interval 46–90 months).

Conclusions

Classification of en bloc sacral resection techniques by the level of nerve root transection is useful in predicting postoperative function and the potential for morbidity. Adequate surgical margins should not be compromised to preserve function when they are necessary to affect tumor control.