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Douglas A. Hardesty, Matthew R. Sanborn, Whitney E. Parker and Phillip B. Storm

Object

The incidence of, and risk factors for, perioperative seizures and the need for perioperative antiepileptic drugs (AEDs) in previously seizure-free children with brain tumors remains unclear. The authors have undertaken a review of previously seizure-free pediatric patients with brain tumors undergoing resection to identify the incidence of seizures in the perioperative period, and to characterize risk factors for perioperative seizures in this population.

Methods

A retrospective review was conducted of all patients between 0 and 19 years of age without prior seizures who underwent intracranial tumor resection at the authors' institution between January 2005 and December 2009.

Results

Of the 223 patients undergoing 229 operations, 7.4% experienced at least 1 clinical seizure during the surgical admission. Over half of all tumors were supratentorial. Only 4.4% of patients received prophylactic AEDs. Independent factors associated with perioperative seizures included supratentorial tumor, age < 2 years, and hyponatremia due to syndrome of inappropriate antidiuretic hormone or cerebral salt wasting. Tumor type, lobe affected, operative blood loss, and length of surgery were not independently associated with seizure incidence.

Conclusions

Perioperative seizures in previously seizure-free children undergoing resection of brain tumors are associated with supratentorial tumor location, age < 2 years, and postoperative hyponatremia. Perioperative seizures are not associated with tumor pathology, tumor size, or frontotemporal location. Due to the low incidence of seizures in this series in patients more than 2 years old with normal serum sodium, the authors recommend that pediatric patients with brain tumors not routinely receive perioperative prophylactic AEDs. However, the role for prophylaxis in patients younger than 2 years of age deserves further study.

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Harjot Thind, Douglas A. Hardesty, Joseph M. Zabramski, Robert F. Spetzler and Peter Nakaji

OBJECT

The successful treatment of an intracranial dural arteriovenous fistula (dAVF) requires complete obliteration of blood flow through the fistulous point. Surgical ligation is often used along with endovascular techniques. Digital subtraction angiography (DSA) can be used to confirm fistula obliteration; however, this technique can be cumbersome intraoperatively and difficult to correlate anatomically with the surgical field. Near-infrared indocyanine green (ICG) videoangiography has been described as a complementary tool for this purpose.

METHODS

The authors examined intracranial dAVF cases in which microscope-integrated intraoperative ICG videoangiography was used to identify and/or confirm obliteration of the dAVF during surgery. Retrospective evaluation of all intracranial dAVF cases treated with surgical ligation over a 10-year period at the Barrow Neurological Institute (n = 47) revealed 28 cases in which ICG videoangiography was used. The results were compared with findings on preoperative and intraoperative or postoperative DSA.

RESULTS

ICG videoangiography successfully confirmed the fistulous point intraoperatively in 96% (22/23) of the cases. It also revealed complete obliteration of fistulas, comparable to intraoperative or postoperative DSA, in 91% (21/23) of the cases. The false-negative rate of ICG was 8.7% (2/23), which is similar to the false-negative rate of intraoperative DSA alone (10.5% [2/19]).

CONCLUSIONS

Microscope-based ICG videoangiography provides real-time information about the intraoperative anatomy of dAVFs. In addition, it can confirm complete obliteration of a fistula. This technique may be useful during dAVF surgery as an independent form of angiography or as an adjunct to intraoperative or postoperative DSA.

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Tyler S. Cole, Sirin Gandhi, Justin R. Mascitelli, Douglas Hardesty, Claudio Cavallo and Michael T. Lawton

Venous interruption through surgical clip ligation is the gold standard treatment for ethmoidal dural arteriovenous fistula (e-dAVF). Their malignant natural history is attributable to the higher predilection for retrograde cortical venous drainage. This video illustrates an e-dAVF in a 70-year-old man with progressive tinnitus and headache. Angiogram revealed bilateral e-dAVFs (Borden III–Cognard III) with one fistula draining into cavernous sinus and another to the sagittal sinus. A bifrontal craniotomy was utilized for venous interruption of both e-dAVFs. Postoperative angiography confirmed curative obliteration with no postoperative anosmia. Bilateral e-dAVFs are rare but can be safely treated simultaneously through a single craniotomy.

The video can be found here: https://youtu.be/666edwKHGKc.

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Michael A. Mooney, Douglas A. Hardesty, John P. Sheehy, Robert Bird, Kristina Chapple, William L. White and Andrew S. Little

OBJECTIVE

The goal of this study was to determine the interrater and intrarater reliability of the Knosp grading scale for predicting pituitary adenoma cavernous sinus (CS) involvement.

METHODS

Six independent raters (3 neurosurgery residents, 2 pituitary surgeons, and 1 neuroradiologist) participated in the study. Each rater scored 50 unique pituitary MRI scans (with contrast) of biopsy-proven pituitary adenoma. Reliabilities for the full scale were determined 3 ways: 1) using all 50 scans, 2) using scans with midrange scores versus end scores, and 3) using a dichotomized scale that reflects common clinical practice. The performance of resident raters was compared with that of faculty raters to assess the influence of training level on reliability.

RESULTS

Overall, the interrater reliability of the Knosp scale was “strong” (0.73, 95% CI 0.56–0.84). However, the percent agreement for all 6 reviewers was only 10% (26% for faculty members, 30% for residents). The reliability of the middle scores (i.e., average rated Knosp Grades 1 and 2) was “very weak” (0.18, 95% CI −0.27 to 0.56) and the percent agreement for all reviewers was only 5%. When the scale was dichotomized into tumors unlikely to have intraoperative CS involvement (Grades 0, 1, and 2) and those likely to have CS involvement (Grades 3 and 4), the reliability was “strong” (0.60, 95% CI 0.39–0.75) and the percent agreement for all raters improved to 60%. There was no significant difference in reliability between residents and faculty (residents 0.72, 95% CI 0.55–0.83 vs faculty 0.73, 95% CI 0.56–0.84). Intrarater reliability was moderate to strong and increased with the level of experience.

CONCLUSIONS

Although these findings suggest that the Knosp grading scale has acceptable interrater reliability overall, it raises important questions about the “very weak” reliability of the scale's middle grades. By dichotomizing the scale into clinically useful groups, the authors were able to address the poor reliability and percent agreement of the intermediate grades and to isolate the most important grades for use in surgical decision making (Grades 3 and 4). Authors of future pituitary surgery studies should consider reporting Knosp grades as dichotomized results rather than as the full scale to optimize the reliability of the scale.

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Joel A. Bauman, Douglas A. Hardesty, Gregory G. Heuer and Phillip B. Storm

An alternative method of bone grafting for pediatric posterior cervical and occipitocervical fixation is presented in detail. Full-thickness autografts from small craniectomies of the occipital bone are used to augment posterior segmental fusion in pediatric patients. Twelve patients have been treated successfully without bone graft donor site complications. The technical differences from previously reported uses of calvarial autograft in spine fusion are reviewed.

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Robert T. Wicks, Xiaochun Zhao, Douglas A. Hardesty, Brandon D. Liebelt and Peter Nakaji

Ethmoidal dural arteriovenous fistulas (DAVFs) have a near-universal association with cortical venous drainage and a malignant clinical course. Endovascular treatment options are often limited due to the high frequency of ophthalmic artery ethmoidal supply. A 64-year-old gentleman presented with syncope and was found to have a right ethmoidal DAVF. Rather than the traditional bicoronal craniotomy, an endoscope-assisted mini-pterional approach for clip ligation is demonstrated. The mini-pterional craniotomy allows a minimally invasive approach to ethmoidal DAVF via a lateral trajectory. The endoscope can help achieve full visualization in the narrow corridor.

The video can be found here: https://youtu.be/ZroXp-T35DI.

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Ian F. Dunn and E. Antonio Chiocca

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Douglas A. Hardesty, Wyatt Ramey, Mohammad Afrasiabi, Brian Beck, Omar Gonzalez, Ana Moran and Peter Nakaji

Object

Coccidioidomycosis is a common fungal infection in the southwestern US. Hydrocephalus is a serious complication of cranial coccidioidomycosis, and the surgical management of coccidioidomycosis-related hydrocephalus has unique challenges. The authors reviewed their institutional experience with hydrocephalus in the setting of coccidioidomycosis.

Methods

The authors retrospectively identified 44 patients diagnosed with coccidioidomycosis-related hydrocephalus at their institution since 1990, who underwent a total of 99 shunting procedures. The authors examined patient demographics, type of shunt and valve used, pressure settings, failure rates, medical treatment, ventricular response to shunting, and other variables.

Results

The majority of patients were young (average age 37 years) men (male/female ratio 28:16) with a mean follow-up of 63 months. Patients of Asian and African descent were overrepresented in the cohort compared with regional demographic data. The overall shunt failure rate during follow-up was 50%, and the average number of revisions required if the shunt failed was 2.5 (range 1–8). Low to moderate draining pressures (mean 88 mm H2O) were used in this cohort. Fourteen patients received intrathecal antifungals, and a trend of initiating intrathecal therapy after need for a shunt revision was observed (p = 0.051). The majority of shunt failures (81%) were due to mechanical blockages in the drainage system. Most patients (59%) had at least partial persistent postoperative ventriculomegaly despite successful CSF diversion. Four patients (9%) died due to coccidioidomycosis during the follow-up period.

Conclusions

Coccidioidomycosis-related hydrocephalus more often affected young males in the study's cohort, especially those of African and Asian descent. Despite the best medical therapy, there was a high rate of shunt failure due to clogged catheters or valves due to the underlying disease process. Many patients continued to have ventriculomegaly even with adequate CSF diversion. The morbidity and mortality of this chronic disease process must be recognized by the treatment team, and patients should be appropriately counseled.

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Douglas A. Hardesty, Andrew B. Wolf, David G. Brachman, Heyoung L. McBride, Emad Youssef, Peter Nakaji, Randall W. Porter, Kris A. Smith, Robert F. Spetzler and Nader Sanai

Object

Patients with atypical meningioma often undergo gross-total resection (GTR) at initial presentation, but the role of adjuvant radiation therapy remains unclear. The increasing prevalence of stereotactic radiosurgery (SRS) in the modern neurosurgical era has led to the use of routine postoperative radiation therapy in the absence of evidence-based guidelines. This study sought to define the long-term recurrence rate of atypical meningiomas and identify the value of SRS in affecting outcome.

Methods

The authors identified 228 patients with microsurgically treated atypical meningiomas who underwent a total of 257 resections at the Barrow Neurological Institute over the last 20 years. Atypical meningiomas were diagnosed according to current WHO criteria. Clinical and radiographic data were collected retrospectively.

Results

Median clinical and radiographic follow-up was 52 months. Gross-total resection, defined as Simpson Grade I or II resection, was achieved in 149 patients (58%). The median proliferative index was 6.9% (range 0.4%–20.6%). Overall 51 patients (22%) demonstrated tumor recurrence at a median of 20.2 months postoperatively. Seventy-one patients (31%) underwent adjuvant radiation postoperatively, with 32 patients (14%) receiving adjuvant SRS and 39 patients (17%) receiving adjuvant intensity modulated radiation therapy (IMRT). The recurrence rate for patients receiving SRS was 25% (8/32) and for IMRT was 18% (7/39), which was not significantly different from the overall group. Gross-total resection was predictive of progression-free survival (PFS; relative risk 0.255, p < 0.0001), but postoperative SRS was not associated with improved PFS in all patients or in only those with subtotal resections.

Conclusions

Atypical meningiomas are increasingly irradiated, even after complete or near-complete microsurgical resection. This analysis of the largest patient series to date suggests that close observation remains reasonable in the setting of aggressive microsurgical resection. Although postoperative adjuvant SRS did not significantly affect tumor recurrence rates in this experience, a larger cohort study with longer follow-up may reveal a therapeutic benefit in the future.

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Gregory G. Heuer, Douglas A. Hardesty, Kareem A. Zaghloul, Erin M. Simon Schwartz, A. Reghan Foley and Phillip B. Storm

Schizencephaly is a rare congenital cortical brain malformation defined by unilateral or bilateral clefts of the cerebral hemispheres. These malformations are often associated with medically intractable epilepsy. Surgical solutions include lesionectomy, lobectomy, or hemispherectomy. The authors describe the case of an anatomic hemispherectomy for medically intractable epilepsy in an 8-year-old boy with a large schizencephalic cleft. Seven years prior to his epilepsy surgery, the patient underwent placement of a ventriculoperitoneal shunt for communicating hydrocephalus that resulted in severe left-to-right shift. Subsequently, medically refractory epilepsy developed and the patient underwent an anatomic hemispherectomy for seizure control. The preoperative brain shift remained after the surgery, although the patient tolerated the procedure well and was seizure free postoperatively. Anatomic hemispherectomy is a viable option for treating medically intractable epilepsy in a schizencephalic pediatric patient—even one with considerable brain shift.