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Mark Bernstein, Alfonso Villamil, George Davidson and Charles Erlichman

✓ Radiological and clinical evidence of acute necrosis in a meningioma following one cycle of chemotherapy with 5-fluorouracil, folinic acid, and levamisole was observed in a patient being treated for invasive rectal carcinoma. The possible mechanisms and implications of this occurrence are discussed.

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Joao Paulo Almeida, Carlos Velásquez, Claire Karekezi, Miguel Marigil, Mojgan Hodaie, James T. Rutka and Mark Bernstein

OBJECTIVE

International collaborations between high-income (HICs) and low- and middle-income countries (LMICs) have been developed as an attempt to reduce the inequalities in surgical care around the world. In this paper the authors review different models for international surgical education and describe projects developed by the Division of Neurosurgery at the University of Toronto in this field.

METHODS

The authors conducted a review of models of international surgical education reported in the literature in the last 15 years. Previous publications on global neurosurgery reported by the Division of Neurosurgery at the University of Toronto were reviewed to exemplify the applications and challenges of international surgical collaborations.

RESULTS

The most common models for international surgical education and collaboration include international surgical missions, long-term international partnerships, fellowship training models, and online surgical education. Development of such collaborations involves different challenges, including limited time availability, scarce funding/resources, sociocultural barriers, ethical challenges, and lack of organizational support. Of note, evaluation of outcomes of international surgical projects remains limited, and the development and application of assessment tools, such as the recently proposed Framework for the Assessment of International Surgical Success (FAIRNeSS), is encouraged.

CONCLUSIONS

Actions to reduce inequality in surgical care should be implemented around the world. Different models can be used for bilateral exchange of knowledge and improvement of surgical care delivery in regions where there is poor access to surgical care. Implementation of global neurosurgery initiatives faces multiple limitations that can be ameliorated if systematic changes occur, such as the development of academic positions in global surgery, careful selection of participant centers, governmental and nongovernmental financial support, and routine application of outcome evaluation for international surgical collaborations.

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Adrian W. Laxton, Patrick Shannon, Sukriti Nag, Richard I. Farb and Mark Bernstein

✓ This 39-year-old man presented with a 6-month history of occipital headaches. Magnetic resonance imaging revealed an irregularly shaped fourth ventricle mass. One month after his initial presentation, he was admitted to the hospital with significant tumor expansion and clinical deterioration. A posterior fossa craniectomy was performed and the mass was resected. Histopathological analysis of this tumor showed central necrosis with associated edema in an otherwise typical and benign-appearing subependymoma. To the authors' knowledge, this is the first reported case of rapid, nonhemorrhagic expansion associated with necrosis in a previously asymptomatic subependymoma.

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Kathleen Joy Khu, Francesco Doglietto, Ivan Radovanovic, Faisal Taleb, Daniel Mendelsohn, Gelareh Zadeh and Mark Bernstein

Object

Routine and nonselective use of awake and outpatient craniotomy for supratentorial tumors has been shown to be safe and effective from a medical standpoint. In this study the authors aim was to explore patients' perceptions about awake and outpatient craniotomy.

Methods

Qualitative research methodology was used. Two semistructured, open-ended interviews were conducted with 27 participants, who were ambulatory adult patients who underwent craniotomy for brain tumor excision between October 2008 and April 2009. The participants were each assigned to one of the following categories: 1) awake outpatient; 2) awake inpatient; 3) outpatient under general anesthesia; and 4) inpatient under general anesthesia. Interviews were audiotaped and transcribed, and the data were subjected to thematic analysis.

Results

The following 6 overarching themes emerged from the data: 1) patients had a positive experience with awake craniotomy; 2) patient satisfaction with outpatient surgery was high; 3) patients understood the rationale behind awake surgery; 4) patients were surprised that brain surgery can be done on an outpatient basis; 5) trust in one's surgeon was important; and 6) patients were more concerned about the disease than the procedure.

Conclusions

The results reflected positively on the patients' awake and outpatient surgery experience, but there were some areas that require improvement, specifically perioperative pain control and postoperative care. These insights on patients' perspectives can lead to better delivery of care, and ultimately, improved health outcomes.

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Edward R. Laws, Ian F. Parney, Wei Huang, Fred Anderson, Angel M. Morris, Anthony Asher, Kevin O. Lillehei, Mark Bernstein, Henry Brem, Andrew Sloan, Mitchel S. Berger, Susan Chang and Glioma Outcomes Investigators

Object. The Glioma Outcomes Project represents a contemporary analysis of the management of malignant (Grade III and Grade IV/GBM) gliomas in North America. This observational database was used to evaluate the influence of resection, as opposed to biopsy, on patient outcome as measured by the length of survival. Attempts were made to reduce the impact of selection bias by repeating the data analysis after omitting patients with major negative prognostic factors.

Methods. Outcome data from 788 patients accrued from multiple sites over a 4-year period (1997–2001) were analyzed with the primary outcome measure being length of survival. Of these, 565 patients with recent diagnoses formed the basis of the present analysis. Patients were systematically followed up until death or up to 24 months after enrollment in the study, and survival data were correlated with the histopathological grade and location of the tumor, the extent of surgery, the patient's performance status, and demographic factors.

The median length of survival was 40.9 weeks for patients with recently diagnosed GBMs. The true median length of survival for patients with Grade III gliomas was not reached, although there was a 58% survival rate at 104 weeks. In multivariate analysis, resection rather than biopsy (p < 0.0001), age 60 years or younger (p < 0.0001), and a Karnofsky Performance Scale (KPS) score of 70 or greater (p = 0.0004) were associated with a prolonged survival time for patients with Grade III or IV gliomas. The prognostic value of resection compared with biopsy was maintained (p < 0.0001), even after eliminating patients considered to be “poor risk” (those with age > 60 years, KPS score < 70, or presence of multifocal tumors), who may have been overrepresented in the biopsy group. Survival “tails” at 24 months were 58% for Grade III gliomas and 11% for GBMs.

Conclusions. These data provide Class II evidence to support tumor grade, patient's age, and patient's functional status as prognostic factors for survival in individuals with recently diagnosed malignant gliomas. Resection (compared with biopsy) is also a strong prognostic factor; however, no quantitative attempt was made to assess the true extent of the resection.

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Georgios Tsermoulas, Mazda K. Turel, Jared T. Wilcox, David Shultz, Richard Farb, Gelareh Zadeh and Mark Bernstein

OBJECTIVE

Multiple meningiomas account for 1%–10% of meningiomas. This study describes epidemiological aspects of the disease and its management, which is more challenging than for single tumors.

METHODS

A consecutive series of adult patients with ≥ 2 spatially separated meningiomas was reviewed. Patients with neurofibromatosis Type 2 were excluded. The authors collected clinical, imaging, histological, and treatment data to obtain information on epidemiology, management options, and outcomes of active treatment and surveillance.

RESULTS

A total of 133 consecutive patients were included over 25 years, with a total of 395 synchronous and 53 metachronous meningiomas, and a median of 2 tumors per patient. One hundred six patients had sporadic disease, 26 had radiation-induced disease, and 1 had familial meningiomatosis. At presentation, half of the patients were asymptomatic. In terms of their maximum cross-sectional diameter, the tumors were small (≤ 2 cm) in 67% and large (> 4 cm) in 11% of the meningiomas. Fifty-four patients had upfront treatment, and 31 had delayed treatment after an observation period (mean 4 years). One in 4 patients had ≥ 2 meningiomas treated. Overall, 64% of patients had treatment for 142 tumors—67 with surgery and 18 with radiotherapy alone. The mean follow-up was 7 years, with 13% of treated patients receiving salvage therapy. Approximately 1 in 4 patients who underwent surgery had ≥ 1 WHO Grade II or III meningioma. Meningiomas of different histological subtypes and grades in the same patient were not uncommon.

CONCLUSIONS

Multiple meningiomas are often asymptomatic, probably because the majority are small and a significant proportion are induced by radiation. Approximately two-thirds of patients with multiple meningiomas require therapy, but only one-third of all meningiomas need active treatment. The authors recommend surveillance for stable and asymptomatic meningiomas and therapy for those that are symptomatic or growing.

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George M. Ibrahim, Benjamin W. Barry, Aria Fallah, O. Carter Snead III, James M. Drake, James T. Rutka and Mark Bernstein

Epilepsy is a common childhood condition associated with a considerable medical and psychosocial burden. Children in whom medical treatment fails to reduce seizure burden represent an especially vulnerable patient population because prolonged, uncontrolled seizures are associated with poor developmental and neurocognitive outcomes. Surgical treatment in the form of cortical resection, functional disconnection, or neuromodulation may alleviate or significantly reduce the disease burden for a subset of these patients. However, there remains a dichotomy between the perceived benefits of surgery and the implementation of surgical strategies in the management of medically intractable epilepsy. The current paper presents an analysis of the bioethical implications of existing inequities in access to pediatric epilepsy surgery that result from inconsistent referral practices and discrepant evaluation techniques. The authors provide a basic bioethical framework composed of 5 primary expectations to inform public, institutional, and personal policies toward the provision of epilepsy surgery to afflicted children.

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Jason S. Day, Michael C. Hurley, Mohamad Chmayssani, Rudy J. Rahme, Mark J. Alberts, Richard A. Bernstein, Guilherme Dabus, Ali Shaibani and Bernard R. Bendok

Object

Endovascular treatment of acute ischemic stroke delivers direct therapy at the site of an occluded cerebral artery and can be employed beyond the 3–4.5-hour window limit set for intravenous recombinant tissue plasminogen activator. In this paper, the authors report their experience with various endovascular therapies in acute ischemic stroke.

Methods

The authors conducted a retrospective review of their clinical database for acute ischemic stroke in large-vessel cerebral territories that underwent endovascular treatment between May 2005 and February 2009. Endovascular treatment was defined as pharmacological and/or mechanical intervention, angioplasty, stenting, or a combination of these methods. Admission National Institutes of Health Stroke Scale and the modified Rankin Scale scores were recorded. Thrombolysis in Myocardial Infarction (TIMI) scores of 0, 1, 2A, 2B, and 3 were used to define recanalization.

Results

Forty procedures were performed in 39 patients, with 1 patient having sequential bilateral strokes. Nine patients were lost to follow-up after discharge. Strokes in the carotid artery circulation occurred in 82.5% of cases, and those in the vertebral-basilar territory occurred in 17.5%. The Merci device was used in 22 (55%) of 40 procedures, and the Penumbra device in 9 (22.5%) of 40. Angioplasty was performed in 15 (37.5%) of 40 procedures, and intraarterial recombinant tissue plasminogen activator was administered in 23 (57.5%) of 40 procedures. In 23 (57.5%) of 40 cases, multiple recanalization methods were used. The recanalization rate for all methods was 60%. The recanalization rate from TIMI Score 0/1 occlusions was 71.4% (20 of 28). An estimated modified Rankin Scale score of ≤ 2 was obtained in 11 (36.7%) of 30 cases. The overall mortality rate was 26.7% (8 of 30). Intracerebral hemorrhage at 24 hours postprocedure was noted in 17 (42.5%) of 40 cases, 3 (7.5%) of which were symptomatic.

Conclusions

The authors' institution performs endovascular stroke treatment with a safety and efficacy profile comparable to those of other major endovascular stroke therapy studies. Recanalization was associated with an improved clinical outcome. Protocols to maximize efficient triage of patients and better documentation of stroke treatments can assist in further studies.

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Susan M. Chang, Ian F. Parney, Michael Mcdermott, Fred G. Barker II, Meic H. Schmidt, Wei Huang, Edward R. Laws Jr., Kevin O. Lillehei, Mark Bernstein, Henry Brem, Andrew E. Sloan, Mitchel Berger and the Glioma Outcomes Investigators

Object. In many new clinical trials of patients with malignant gliomas surgical intervention is incorporated as an integral part of tumor-directed interstitial therapies such as gene therapy, biodegradable wafer placement, and immunotherapy. Assessment of toxicity is a major component of evaluating these novel therapeutic interventions, but this must be done in light of known complication rates of craniotomy for tumor resection. Factors predicting neurological outcome would also be helpful for patient selection for surgically based clinical trials.

Methods. The Glioma Outcome Project is a prospectively compiled database containing information on 788 patients with malignant gliomas that captured clinical practice patterns and patient outcomes. Patients in this series who underwent their first or second craniotomy were analyzed separately for presenting symptoms, tumor and patient characteristics, and perioperative complications. Preoperative and intraoperative factors possibly related to neurological outcome were evaluated.

There were 408 patients who underwent first craniotomies (C1 group) and 91 patients who underwent second ones (C2 group). Both groups had similar patient and tumor characteristics except for their median age (55 years in the C1 group compared with 50 years in the C2 group; p = 0.006). Headache was more common at presentation in the C1 group, whereas papilledema and an altered level of consciousness were more common at presentation in patients undergoing second surgeries. Perioperative complications occurred in 24% of patients in the C1 group and 33% of patients in the C2 group (p = 0.1). Most patients were the same or better neurologically after surgery, but more patients in the C2 group (18%) displayed a worsened neurological status than those in the C1 group (8%; p = 0.007). The Karnofsky Performance Scale score and, in patients in the C2 group, tumor size were important neurological outcome predictors. Regional complications occurred at similar rates in both groups. Systemic infections occurred more frequently in the C2 group (4.4 compared with 0%; p < 0.0001) as did depression (20 compared with 11%; p = 0.02). The perioperative mortality rate was 1.5% for the C1 group and 2.2% for the C2 group (p = not significant). The median length of the hospital stay was 4 days in each group.

Conclusions. Perioperative complications occur slightly more often following a second craniotomy for malignant glioma than after the first craniotomy. This should be considered when evaluating toxicities from intraoperative local therapies requiring craniotomy. Nevertheless, most patients are neurologically stable or improved after either their first or second craniotomy. This data set may serve as a benchmark for neurosurgeons and others in a discussion of operative risks in patients with malignant gliomas.

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Li Wang, Wei Chen, Fujun Liu, Li F. Zhang and Jing Chen