Monika M. Połczyńska, Lilian Beck, Taylor Kuhn, Christopher F. Benjamin, Timothy K. Ly, Kevin Japardi, Lucia Cavanagh, and Susan Y. Bookheimer
Brain tumors located close to the language cortex may distort functional MRI (fMRI)–based estimates of language dominance. The nature of this distortion, and whether this is an artifact of numerous confounders, remains unknown. The authors hypothesized tumor bias based on laterality estimates independent of confounders and that the effects are the greatest for tumors proximal to Broca's area.
To answer this question, the authors reviewed more than 1113 patients who underwent preoperative fMRI to match samples on 11 known confounders (tumor location, size, type, and grade; seizure history; prior neurosurgery; aphasia presence and severity; and patient age, sex, and handedness). The samples included 30 patients with left hemisphere tumors (15 anterior and 15 posterior) and 30 with right hemisphere tumors (15 anterior and 15 posterior), thus totaling 60 patients (25 women; 18 left-handed and 4 ambidextrous; mean age 47 [SD 14.1] years). Importantly, the authors matched not only patients with left and right hemisphere tumors but also those with anterior and posterior tumors. Standard fMRI laterality indices (LIs) were calculated using whole-brain and region of interest (ROI) approaches (Broca's and Wernicke's areas).
Tumors close to Broca's area in the left hemisphere decreased LIs independently of known confounders. At the whole-brain level, this appeared to reflect a decrease in LI values in patients with left anterior tumors compared with patients with right anterior tumors. ROI analysis replicated these findings. Broca's area LIs were significantly lower (p = 0.02) in patients with left anterior tumors (mean LI 0.28) when compared with patients with right anterior tumors (mean LI 0.70). Changes in Wernicke's area–based LIs did not differ as a function of the tumor hemisphere. Therefore, in patients with left anterior tumors, it is essential to assess language laterality using left posterior ROIs. In all remaining tumor groups (left posterior tumors and right hemisphere tumors), language laterality derived from the anterior language ROI was the most robust measure of language dominance.
Patients with tumors close to Broca's area showed more bilateral fMRI language maps independent of known confounders. The authors caution against the assumption that this reduced language laterality suggests no or little risk to language function following tumor resection in the left inferior frontal gyrus. Their results address how to interpret fMRI data for neurosurgical purposes, along with theoretical questions of contralesional functional compensation and disinhibition.
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
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.
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.
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%).
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.
Brian J. Williams, Dima Suki, Benjamin D. Fox, Christopher E. Pelloski, Marcos V. C. Maldaun, Raymond E. Sawaya, Frederick F. Lang, and Ganesh Rao
Stereotactic radiosurgery (SRS) is commonly used to treat brain metastases. Complications associated with this treatment are underreported. The authors reviewed a large series of patients who underwent SRS for brain metastases to identify complications and factors predicting their occurrence.
Prospectively collected clinical data from 273 patients undergoing SRS for 1 or 2 brain metastases at The University of Texas M. D. Anderson Cancer Center between June 1993 and December 2004 were reviewed. Patients who had received prior treatment for their tumor, including whole-brain radiation, SRS, or surgery, were excluded from the study. Data on adverse neurological and nonneurological outcomes following treatment were collected.
Three hundred sixteen lesions were treated. Complications were associated with 127 (40%) of 316 treated lesions. New neurological complications were associated with 101 (32%) of 316 lesions. The onset of seizure was the most common complication, occurring in 41 (13%) of 316 SRS cases. On multivariate analysis, progressing primary cancer (hazard ratio [HR] = 2.4, 95% CI 1.6–3.6, p < 0.001), tumor location in eloquent cortex (HR = 2.3, 95% CI 1.6–3.4, p < 0.001), and lower (< 15 Gy) SRS dose (HR = 2.1, 95% CI 1.1–4.2, p = 0.04) were significantly associated with new complications. On multivariate analysis, a tumor location in the eloquent cortex (HR = 2.5, 95% CI 1.6–3.8, p < 0.001) and progressing primary cancer (HR = 1.6, 95% CI 1.1–2.5, p = 0.03) were significantly associated with new neurological complications.
The authors showed that new neurological and nonneurological complications were associated with 40% of SRS treatments for brain metastases. Patients with lesions in functional brain regions have a significantly increased risk of treatment-related complications.
Visish M. Srinivasan, Aditya Srivatsan, Alejandro M. Spiotta, Benjamin K. Hendricks, Andrew F. Ducruet, Felipe C. Albuquerque, Ajit Puri, Matthew R. Amans, Steven W. Hetts, Daniel L. Cooke, Christopher S. Ogilvy, Ajith J. Thomas, Alejandro Enriquez-Marulanda, Ansaar Rai, SoHyun Boo, Andrew P. Carlson, R. Webster Crowley, Leonardo Rangel-Castilla, Giuseppe Lanzino, Peng Roc Chen, Orlando Diaz, Bradley N. Bohnstedt, Kyle P. O’Connor, Jan-Karl Burkhardt, Jeremiah N. Johnson, Stephen R. Chen, and Peter Kan
Traditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device.
This study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications.
A total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2.
PulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist’s armamentarium, especially with regard to its off-label use.
Praveen V. Mummaneni, John F. Burke, Andrew K. Chan, Julie Ann Sosa, Errol P. Lobo, Valli P. Mummaneni, Sheila Antrum, Sigurd H. Berven, Michael S. Conte, Sarah B. Doernberg, Andrew N. Goldberg, Christopher P. Hess, Steven W. Hetts, S. Andrew Josephson, Maureen P. Kohi, C. Benjamin Ma, Vaikom S. Mahadevan, Annette M. Molinaro, Andrew H. Murr, Sirisha Narayana, John P. Roberts, Marshall L. Stoller, Philip V. Theodosopoulos, Thomas P. Vail, Sandra Wienholz, Michael A. Gropper, Adrienne Green, and Mitchel S. Berger
During the COVID-19 pandemic, quaternary-care facilities continue to provide care for patients in need of urgent and emergent invasive procedures. Perioperative protocols are needed to streamline care for these patients notwithstanding capacity and resource constraints.
A multidisciplinary panel was assembled at the University of California, San Francisco, with 26 leaders across 10 academic departments, including 7 department chairpersons, the chief medical officer, the chief operating officer, infection control officers, nursing leaders, and resident house staff champions. An epidemiologist, an ethicist, and a statistician were also consulted. A modified two-round, blinded Delphi method based on 18 agree/disagree statements was used to build consensus. Significant disagreement for each statement was tested using a one-sided exact binomial test against an expected outcome of 95% consensus using a significance threshold of p < 0.05. Final triage protocols were developed with unblinded group-level discussion.
Overall, 15 of 18 statements achieved consensus in the first round of the Delphi method; the 3 statements with significant disagreement (p < 0.01) were modified and iteratively resubmitted to the expert panel to achieve consensus. Consensus-based protocols were developed using unblinded multidisciplinary panel discussions. The final algorithms 1) quantified outbreak level, 2) triaged patients based on acuity, 3) provided a checklist for urgent/emergent invasive procedures, and 4) created a novel scoring system for the allocation of personal protective equipment. In particular, the authors modified the American College of Surgeons three-tiered triage system to incorporate more urgent cases, as are often encountered in neurosurgery and spine surgery.
Urgent and emergent invasive procedures need to be performed during the COVID-19 pandemic. The consensus-based protocols in this study may assist healthcare providers to optimize perioperative care during the pandemic.
2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010