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Nikita Lakomkin and Constantinos G. Hadjipanayis

OBJECTIVE

Hospital-acquired conditions (HACs) significantly compromise patient safety, and have been identified by the Centers for Medicare and Medicaid Services as events that will be associated with penalties for surgeons. The mitigation of HACs must be an important consideration during the postoperative management of patients undergoing spine tumor resection. The purpose of this study was to identify the risk factors for HACs and to characterize the relationship between HACs and other postoperative adverse events following spine tumor resection.

METHODS

The 2008–2014 American College of Surgeons’ National Surgical Quality Improvement Program database was used to identify adult patients undergoing the resection of intramedullary, intradural extramedullary, and extradural spine lesions via current procedural terminology and ICD-9 codes. Demographic, comorbidity, and operative variables were evaluated via bivariate statistics before being incorporated into a multivariable logistic regression model to identify the independent risk factors for HACs. Associations between HACs and other postoperative events, including death, readmission, prolonged length of stay, and various complications were determined through multivariable analysis while controlling for other significant variables. The c-statistic was computed to evaluate the predictive capacity of the regression models.

RESULTS

Of the 2170 patients included in the study, 195 (9.0%) developed an HAC. Only 2 perioperative variables, functional dependency and high body mass index, were risk factors for developing HACs (area under the curve = 0.654). Hospital-acquired conditions were independent predictors of all examined outcomes and complications, including death (OR 2.26, 95% CI 1.24–4.11, p = 0.007), prolonged length of stay (OR 2.74, 95% CI 1.98–3.80, p < 0.001), and readmission (OR 9.16, 95% CI 6.27–13.37, p < 0.001). The areas under the curve for these models ranged from 0.750 to 0.917.

CONCLUSIONS

The comorbidities assessed in this study were not strongly predictive of HACs. Other variables, including hospital-associated factors, may play a role in the development of these conditions. The presence of an HAC was found to be an independent risk factor for a variety of adverse events. These findings highlight the need for continued development of evidence-based protocols designed to reduce the incidence and severity of HACs.

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Michael C. Dewan, Reid C. Thompson, Steven N. Kalkanis, Fred G. Barker II, and Constantinos G. Hadjipanayis

OBJECTIVE

Antiepileptic drugs (AEDs) are often administered prophylactically following brain tumor resection. With conflicting evidence and unestablished guidelines, however, the nature of this practice among tumor surgeons is unknown.

METHODS

On November 24, 2015, a REDCap (Research Electronic Database Capture) survey was sent to members of the AANS/CNS Section on Tumors to query practice patterns.

RESULTS

Responses were received from 144 individuals, including 18.8% of board-certified neurosurgeons surveyed (across 86 institutions, 16 countries, and 5 continents). The majority reported practicing in an academic setting (85%) as a tumor specialist (71%). Sixty-three percent reported always or almost always prescribing AED prophylaxis postoperatively in patients with a supratentorial brain tumor without a prior seizure history. Meanwhile, 9% prescribed occasionally and 28% rarely prescribed AED prophylaxis. The most common agent was levetiracetam (85%). The duration of seizure prophylaxis varied widely: 25% of surgeons administered prophylaxis for 7 days, 16% for 2 weeks, 21% for 2 to 6 weeks, and 13% for longer than 6 weeks. Most surgeons (61%) believed that tumor pathology influences epileptogenicity, with high-grade glioma (39%), low-grade glioma (31%), and metastases (24%) carrying the greatest seizure risk. While the majority used prophylaxis, 62% did not believe or were unsure if prophylactic AEDs reduced seizures postoperatively. The vast majority (82%) stated that a well-designed randomized trial would help guide their future clinical decision making.

CONCLUSIONS

Wide knowledge and practice gaps exist regarding the frequency, duration, and setting of AED prophylaxis for seizure-naive patients undergoing brain tumor resection. Acceptance of universal practice guidelines on this topic is unlikely until higher-level evidence supporting or refuting the value of modern seizure prophylaxis is demonstrated.

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Constantinos G. Hadjipanayis, Ghassan Bejjani, Clayton Wiley, Toshinori Hasegawa, Melissa Maddock, and Douglas Kondziolka

✓ Sinus histiocytosis or Rosai—Dorfman disease (RDD) is a rare idiopathic histioproliferative disorder typically characterized by painless cervical lymphadenopathy, fever, and weight loss. Extranodal, intracranial disease is uncommon. In this report the authors describe the first case of intracranial RDD treated with stereotactic radiosurgery after resection.

This 52-year-old man with known RDD presented with a 7-day course of fever, headache, diplopia, left facial paresthesias, and difficulty swallowing. No cranial nerve deficits were evident on examination, but right submandibular and inguinal node enlargements were noted. On neuroimaging, the patient was found to have a homogeneously contrast-enhancing petroclival lesion with extension into the left cavernous sinus.

The patient underwent a combined left petrosal craniotomy and partial labyrinthectomy with duraplasty for biopsy sampling and partial microsurgical resection of the lesion. Microscopic examination of the biopsy specimen revealed the presence of a mixed cellular population with predominant mature histiocytes consistent with RDD. The residual tumor was treated with stereotactic radiosurgery 2 months after resection. On follow-up imaging the lesion had regressed significantly, with only slight dural enhancement remaining.

Microsurgical resection for histological diagnosis, followed by stereotactic radiosurgery for residual tumor represents one treatment alternative in the management of intracranial RDD in which a complete resection carries the potential for excess morbidity.

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Constantinos G. Hadjipanayis, Douglas Kondziolka, Paul Gardner, Ajay Niranjan, Shekhar Dagam, John C. Flickinger, and L. Dade Lunsford

Object. The goal of this study was to examine the role of stereotactic radiosurgery in the treatment of patients with recurrent or unresectable pilocytic astrocytomas.

Methods. During a 13-year interval, 37 patients (median age 14 years) required multimodal treatment of recurrent or unresectable pilocytic astrocytomas. Tumors involved the brainstem in 18 patients, cerebellum in three, thalamus in five, temporal lobe in four, and parietal lobe in two, as well as the hypothalamus, optic tract, corpus callosum, insular cortex, and third ventricle in one patient each. Diagnosis was confirmed with the aid of stereotactic biopsy in 12 patients, open biopsy in five, partial resection in eight, and near-total resection in 12. Multimodal treatment included fractionated radiation therapy in 10 patients, stereotactic intracavitary irradiation of tumor in four, chemotherapy in two, cyst drainage in six, ventriculoperitoneal shunt placement in three, and additional cytoreductive surgery in four. Tumor volumes varied from 0.42 to 25 cm3. The median radiosurgical dose to the tumor margin was 15 Gy (range 9.6–22.5 Gy).

After radiosurgery, serial imaging demonstrated complete tumor resolution in 10 patients, reduced tumor volume in eight, stable tumor volume in seven, and delayed tumor progression in 12. No procedure-related death was encountered. Thirty-three (89%) of 37 patients are alive at a median follow-up period of 28 months after radiosurgery and 59 months after diagnosis. Eight patients participated in follow-up review for more than 60 months. Three patients died of local tumor progression.

Conclusions. Stereotactic radiosurgery is a valuable adjunctive strategy in the management of recurrent or unresectable pilocytic astrocytomas. Despite the favorable histological characteristics and prognosis usually associated with this neoplasm, an adverse location, recurrence, or progression of this disease requires alternative therapeutic approaches such as radiosurgery.

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Spinal cord injury in the United States Army Special Forces

Presented at the 2020 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Remi A. Kessler, Ansh Bhammar, Nikita Lakomkin, Raj K. Shrivastava, Jonathan J. Rasouli, Jeremy Steinberger, Joshua Bederson, Constantinos G. Hadjipanayis, and Deborah L. Benzil

OBJECTIVE

Spinal cord injury (SCI) is an area of key interest in military medicine but has not been studied among the US Army Special Forces (SF), the most elite group of US soldiers. SF soldiers make up a disproportionate 60% of all Special Operations casualties. The objective of this study was to better understand SCI incidence in the SF, its mechanisms of acquisition, and potential areas for intervention by addressing key issues pertaining to protective equipment and body armor use.

METHODS

An electronic survey questionnaire was formulated with the close collaboration of US board-certified neurosurgeons from the Mount Sinai Hospital and Cleveland Clinic Departments of Neurosurgery, retired military personnel of the SF, and operational staff of the Green Beret Foundation. The survey was sent to approximately 6000 SF soldiers to understand SCI diagnosis and its associations with various health and military variables.

RESULTS

The response rate was 8.2%. Among the 492 respondents, 94 (19.1%) self-reported an SCI diagnosis. An airborne operation was the most commonly attributed cause (54.8%). Moreover, 87.1% of SF soldiers reported wearing headgear at the time of injury, but only 36.6% reported wearing body armor, even though body armor use has significantly increased in post-9/11 SF soldiers compared with that in their pre-9/11 counterparts. SCI was significantly associated with traumatic brain injury, arthritis, low sperm count, low testosterone, erectile dysfunction, tinnitus, hyperacusis, sleep apnea, posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder. Only 16.5% of SF soldiers diagnosed with SCI had been rescued via medical evacuation (medevac) for treatment.

CONCLUSIONS

A high number of SF soldiers self-reported an SCI diagnosis. Airborne operations landings were the leading cause of SCI, which coincided with warfare tactics employed during the Persian Gulf War, Operation Iraqi Freedom, and other conflicts. A majority of SCIs occurred while wearing headgear and no body armor, suggesting the need for improvements in protective equipment use and design. The low rate of medevac rescue for these injuries may suggest that medical rescue was not attainable at the time or that certain SCIs were deemed minor at the time of injury.

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Georgios P. Skandalakis, Spyridon Komaitis, Aristotelis Kalyvas, Evgenia Lani, Chrysoula Kontrafouri, Evangelos Drosos, Faidon Liakos, Maria Piagkou, Dimitris G. Placantonakis, John G. Golfinos, Kostas N. Fountas, Eftychia Z. Kapsalaki, Constantinos G. Hadjipanayis, George Stranjalis, and Christos Koutsarnakis

OBJECTIVE

Although a growing body of data support the functional connectivity between the precuneus and the medial temporal lobe during states of resting consciousness as well as during a diverse array of higher-order functions, direct structural evidence on this subcortical circuitry is scarce. Here, the authors investigate the very existence, anatomical consistency, morphology, and spatial relationships of the cingulum bundle V (CB-V), a fiber tract that has been reported to reside close to the inferior arm of the cingulum (CingI).

METHODS

Fifteen normal, formalin-fixed cerebral hemispheres from adults were treated with Klingler’s method and subsequently investigated through the fiber microdissection technique in a medial to lateral direction.

RESULTS

A distinct group of fibers is invariably identified in the subcortical territory of the posteromedial cortex, connecting the precuneus and the medial temporal lobe. This tract follows the trajectory of the parietooccipital sulcus in a close spatial relationship with the CingI and the sledge runner fasciculus. It extends inferiorly to the parahippocampal place area and retrosplenial complex area, followed by a lateral curve to terminate toward the fusiform face area (Brodmann area [BA] 37) and lateral piriform area (BA35). Taking into account the aforementioned subcortical architecture, the CB-V allegedly participates as a major subcortical stream within the default mode network, possibly subserving the transfer of multimodal cues relevant to visuospatial, facial, and mnemonic information to the precuneal hub. Although robust clinical evidence on the functional role of this stream is lacking, the modern neurosurgeon should be aware of this tract when manipulating cerebral areas en route to lesions residing in or around the ventricular trigone.

CONCLUSIONS

Through the fiber microdissection technique, the authors were able to provide original, direct structural evidence on the existence, morphology, axonal connectivity, and correlative anatomy of what proved to be a discrete white matter pathway, previously described as the CB-V, connecting the precuneus and medial temporal lobe.

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Georgios P. Skandalakis, Spyridon Komaitis, Aristotelis Kalyvas, Evgenia Lani, Chrysoula Kontrafouri, Evangelos Drosos, Faidon Liakos, Maria Piagkou, Dimitris G. Placantonakis, John G. Golfinos, Kostas N. Fountas, Eftychia Z. Kapsalaki, Constantinos G. Hadjipanayis, George Stranjalis, and Christos Koutsarnakis

OBJECTIVE

Although a growing body of data support the functional connectivity between the precuneus and the medial temporal lobe during states of resting consciousness as well as during a diverse array of higher-order functions, direct structural evidence on this subcortical circuitry is scarce. Here, the authors investigate the very existence, anatomical consistency, morphology, and spatial relationships of the cingulum bundle V (CB-V), a fiber tract that has been reported to reside close to the inferior arm of the cingulum (CingI).

METHODS

Fifteen normal, formalin-fixed cerebral hemispheres from adults were treated with Klingler’s method and subsequently investigated through the fiber microdissection technique in a medial to lateral direction.

RESULTS

A distinct group of fibers is invariably identified in the subcortical territory of the posteromedial cortex, connecting the precuneus and the medial temporal lobe. This tract follows the trajectory of the parietooccipital sulcus in a close spatial relationship with the CingI and the sledge runner fasciculus. It extends inferiorly to the parahippocampal place area and retrosplenial complex area, followed by a lateral curve to terminate toward the fusiform face area (Brodmann area [BA] 37) and lateral piriform area (BA35). Taking into account the aforementioned subcortical architecture, the CB-V allegedly participates as a major subcortical stream within the default mode network, possibly subserving the transfer of multimodal cues relevant to visuospatial, facial, and mnemonic information to the precuneal hub. Although robust clinical evidence on the functional role of this stream is lacking, the modern neurosurgeon should be aware of this tract when manipulating cerebral areas en route to lesions residing in or around the ventricular trigone.

CONCLUSIONS

Through the fiber microdissection technique, the authors were able to provide original, direct structural evidence on the existence, morphology, axonal connectivity, and correlative anatomy of what proved to be a discrete white matter pathway, previously described as the CB-V, connecting the precuneus and medial temporal lobe.

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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.