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Paul Teng and Christos Papatheodorou

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Paul Teng and Christos Papatheodorou

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Konstantinos Margetis, Paul J. Christos and Mark Souweidane

Object

Incidental colloid cysts are frequently managed with surveillance imaging rather than surgical excision. This approach is born out of their purported indolent growth pattern and the surgical morbidity associated with microsurgical removal. The advent of endoscopic colloid cyst removal may offer renewed assessment of these patients who carry a risk of acute neurological deterioration. An evidence-based recommendation should weigh the risks of operative treatment. Thus far, there has been no concentrated assessment of cyst removal in patients with incidental colloid cysts. The major objective in this study was to define the risks associated with the endoscopic surgical removal of incidentally diagnosed colloid cysts

Methods

A retrospective review of the medical records was performed to search for patients evaluated for a colloid cyst between the years 1996 and 2012. Eighty-seven patients underwent colloid cyst resection, and 34 were managed with nonoperative surveillance imaging. Microsurgical resections, endoscopic resections of residual or recurrent colloid cysts, and cases with unknown preoperative symptomatic status were excluded from further analysis. Seventy-seven cases of primary endoscopic resections were identified. Twenty resections were performed in patients with an incidental diagnosis and 57 in symptomatic individuals. Presenting characteristics and surgical outcomes were compared between the incidental and symptomatic groups.

Results

The mean age at surgery was 39.65 years for the incidental and 43.31 years for the symptomatic group (p = 0.36). The median maximal cyst diameter was 9.7 mm (range 3–31 mm) for the incidental and 12 mm (range 5–34 mm) for the symptomatic group. The mean frontal and occipital horn ratio was 0.3928 for the incidental and 0.4445 for the symptomatic group (p = 0.002). Total resection was achieved in 90% of the incidental and 82.3% of the symptomatic cases (p = 0.49). The median hospital stay was 1 day for incidental and 2 days for symptomatic cases (p = 0.006). There were no deaths. There was one case of aseptic meningitis in the incidental group. In the symptomatic group there were 3 complications: one patient with subjective memory impairment, one with transient short-term memory deterioration, and another with a superficial wound infection treated with operative debridement. Two patients from the symptomatic group needed a CSF diversion procedure, and no shunting was needed in the incidental group. There were two recurrences in the symptomatic group (78 and 133 months postoperatively) and none in the incidental group (p = 1).

Conclusions

Age and cyst diameter were not correlated with the absence or presence of symptoms in patients with a colloid cyst of the third ventricle. Operative results were highly favorable in both groups and did not reveal a higher risk of morbidity in the patient presenting with an incidental lesion. The results support endoscopic resection as a legitimate therapeutic option for patients with incidental colloid cysts. Generalization of the operative results should be cautiously made, since this is a limited series and the results may depend on the degree of neuroendoscopic experience.

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Jeffrey P. Greenfield, Caitlin Hoffman, Eugenia Kuo, Paul J. Christos and Mark M. Souweidane

Object

The authors' aim in this study was to determine if standardizing the evaluation of intraoperative findings during endoscopic third ventriculostomy (ETV) could predict patients with hydrocephalus in whom endoscopic treatment will fail and require ventriculoperitoneal shunt treatment. The creation of a uniform scale with predictive outcomes may reduce returns to the operating room for shunt treatment and reliance on postoperative externalized ventricular monitoring and MR imaging.

Methods

The authors evaluated the preoperative history, intraoperative findings, and postoperative monitoring and imaging findings in 109 consecutive patients undergoing 112 consecutive attempted ETVs for obstructive hydrocephalus. A 5-grade scale was developed to assess preoperative risk factors and intraoperative evaluation to unify criteria that have been suspected to influence outcome independently. A grade of 0 was assigned to patients with no negative predictors, whereas increasing scores were assigned to patients who had multiple preoperative and intraoperative risks identified. Patients' grades were compared with outcome of the procedure, utility of externalized ventricular monitoring, and results of postoperative MR imaging.

Results

Of 112 ETVs, 77 were successful and 35 were unsuccessful. Fifty-nine patients received a grade of 0, 27 received a grade of 1, 11 received a grade of 2, and 15 received a grade of ≥ 3. In all 15 patients receiving a grade ≥ 3 attempted ETV procedures failed, and the patients required a ventriculoperitoneal shunt. Postoperative monitoring with externalized ventricular drains and MR images demonstrating radiographic evidence of flow was independently less reliable than intraoperative grading in predicting success. Patients with a grade of 0 almost uniformly had successful surgery, independent of MR imaging findings. Patients with a grade of 1 or 2 who had successful surgery almost always lacked negative intraoperative predictive findings.

Conclusions

Despite reliance in recent years on post-ETV MR images and externalized ventricular monitoring, these modalities, although often useful adjuncts, appear less reliable as predictive tests than a simple assessment at the time of endoscopic fenestration. By using a uniform grading scale, the authors have introduced a novel means through which intraoperative and postoperative decision making can be aided, with the goal of reducing unnecessary procedures and tests and preventing unnecessary returns to the operating room.

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Collin C. Tebo, Alexander I. Evins, Paul J. Christos, Jennifer Kwon and Theodore H. Schwartz

Object

Surgical interventions for medically refractory epilepsy are effective in selected patients, but they are underutilized. There remains a lack of pooled data on complication rates and their changes over a period of multiple decades. The authors performed a systematic review and meta-analysis of reported complications from intracranial epilepsy surgery from 1980 to 2012.

Methods

A literature search was performed to find articles published between 1980 and 2012 that contained at least 2 patients. Patients were divided into 3 groups depending on the procedure they underwent: A) temporal lobectomy with or without amygdalohippocampectomy, B) extratemporal lobar or multilobar resections, or C) invasive electrode placement. Articles were divided into 2 time periods, 1980–1995 and 1996–2012.

Results

Sixty-one articles with a total of 5623 patients met the study's eligibility criteria. Based on the 2 time periods, neurological deficits decreased dramatically from 41.8% to 5.2% in Group A and from 30.2% to 19.5% in Group B. Persistent neurological deficits in these 2 groups decreased from 9.7% to 0.8% and from 9.0% to 3.2%, respectively. Wound infections/meningitis decreased from 2.5% to 1.1% in Group A and from 5.3% to 1.9% in Group B. Persistent neurological deficits were uncommon in Group C, although wound infections/meningitis and hemorrhage/hematoma increased over time from 2.3% to 4.3% and from 1.9% to 4.2%, respectively. These complication rates are additive in patients undergoing implantation followed by resection.

Conclusions

Complication rates have decreased dramatically over the last 30 years, particularly for temporal lobectomy, but they remain an unavoidable consequence of epilepsy surgery. Permanent neurological deficits are rare following epilepsy surgery compared with the long-term risks of intractable epilepsy.

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Neal Luther, William R. Stetler Jr., Ira J. Dunkel, Paul J. Christos, John C. Wellons III and Mark M. Souweidane

Object

Endoscopic biopsy with concomitant third ventriculostomy (ETV) is a well-established diagnostic and therapeutic maneuver in patients presenting with noncommunicating hydrocephalus resulting from a tumor of the pineal region or posterior third ventricle. Fenestration of the floor of the third ventricle theoretically provides a conduit for the subarachnoid dissemination of an intraventricular tumor. The aim of this study was to ascertain the rate of leptomeningeal dissemination following this surgical procedure.

Methods

The authors conducted a review of all patients for whom an ETV and simultaneous endoscopic biopsy procedure or tumor resection had been performed at their institutions between 1995 and 2008. Patients were divided into high or low risk groups by leptomeningeal metastatic potential based on pathology. All available postoperative clinical and radiographic data, including MR imaging of the brain and spinal cord, as well as CSF sampling were evaluated when available. A review of the literature was then conducted to establish rates of distant leptomeningeal dissemination for comparative purposes.

Results

Thirty-two patients satisfied the criteria for study inclusion. Pathology revealed that 22 had a high risk for leptomeningeal dissemination. New leptomeningeal disease (1 yolk sac tumor and 1 pineoblastoma) occurred in 2 patients. The median clinical and brain MR imaging follow-ups overall were 34 (range 2–103 months) and 38 months (range 1–94 months), respectively. Follow-up MR imaging of the spine was performed in 12 patients (median 7 months postoperation), and CSF was analyzed in 15 patients (median 1 month postoperation). A Kaplan-Meier survival analysis predicted a 2-year metastasis-free survival of 94.7% for high-risk patients. Baseline rates of dissemination when ETV was not performed were in general between 8 and 24% for various high-risk pathologies according to a literature review.

Conclusions

The rate of leptomeningeal metastasis of tumors in this biopsy and ETV study was not increased when compared with rates from large series in the literature.

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James M. Drake and Jay Riva-Cambrin

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A. Gabriella Wernicke, Andrew W. Smith, Shoshana Taube, Menachem Z. Yondorf, Bhupesh Parashar, Samuel Trichter, Lucy Nedialkova, Albert Sabbas, Paul Christos, Rohan Ramakrishna, Susan C. Pannullo, Philip E. Stieg and Theodore H. Schwartz

OBJECTIVE

Managing patients whose intraparenchymal brain metastases recur after radiotherapy remains a challenge. Intraoperative cesium-131 (Cs-131) brachytherapy performed at the time of neurosurgical resection may represent an excellent salvage treatment option. The authors evaluated the outcomes of this novel treatment with permanent intraoperative Cs-131 brachytherapy.

METHODS

Thirteen patients with 15 metastases to the brain that recurred after stereotactic radiosurgery and/or whole brain radiotherapy were treated between 2010 and 2015. Stranded Cs-131 seeds were placed as a permanent volume implant. Prescription dose was 80 Gy at 5-mm depth from the resection cavity surface. The primary end point was resection cavity freedom from progression (FFP). Resection cavity freedom from progression (FFP), regional FFP, distant FFP, median survival, overall survival (OS), and toxicity were assessed.

RESULTS

The median duration of follow-up after salvage treatment was 5 months (range 0.5–18 months). The patients' median age was 64 years (range 51–74 years). The median resected tumor diameter was 2.9 cm (range 1.0–5.6 cm). The median number of seeds implanted was 19 (range 10–40), with a median activity per seed of 2.25 U (range 1.98–3.01 U) and median total activity of 39.6 U (range 20.0–95.2 U). The 1-year actuarial local FFP was 83.3%. The median OS was 7 months, and 1-year OS was 24.7%. Complications included infection (3), pseudomeningocele (1), seizure (1), and asymptomatic radionecrosis (RN) (1).

CONCLUSIONS

After failure of prior irradiation of brain metastases, re-irradiation with intraoperative Cs-131 brachytherapy implants provides durable local control and limits the risk of RN. The authors' initial experience demonstrates that this treatment approach is well tolerated and safe for patients with previously irradiated tumors after failure of more than 1 radiotherapy regimen and that it results in excellent response rates and minimal toxicity.

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A. Gabriella Wernicke, Menachem Z. Yondorf, Luke Peng, Samuel Trichter, Lucy Nedialkova, Albert Sabbas, Fridon Kulidzhanov, Bhupesh Parashar, Dattatreyudu Nori, K. S. Clifford Chao, Paul Christos, Ilhami Kovanlikaya, Susan Pannullo, John A. Boockvar, Philip E. Stieg and Theodore H. Schwartz

Object

Resected brain metastases have a high rate of local recurrence without adjuvant therapy. Adjuvant whole-brain radiotherapy (WBRT) remains the standard of care with a local control rate > 90%. However, WBRT is delivered over 10–15 days, which can delay other therapy and is associated with acute and long-term toxicities. Permanent cesium-131 (131Cs) implants can be used at the time of metastatic resection, thereby avoiding the need for any additional therapy. The authors evaluated the safety, feasibility, and efficacy of a novel therapeutic approach with permanent 131Cs brachytherapy at the resection for brain metastases.

Methods

After institutional review board approval was obtained, 24 patients with a newly diagnosed metastasis to the brain were accrued to a prospective protocol between 2010 and 2012. There were 10 frontal, 7 parietal, 4 cerebellar, 2 occipital, and 1 temporal metastases. Histology included lung cancer (16), breast cancer (2), kidney cancer (2), melanoma (2), colon cancer (1), and cervical cancer (1). Stranded 131Cs seeds were placed as permanent volume implants. The prescription dose was 80 Gy at a 5-mm depth from the resection cavity surface. Distant metastases were treated with stereotactic radiosurgery (SRS) or WBRT, depending on the number of lesions. The primary end point was local (resection cavity) freedom from progression (FFP). Secondary end points included regional FFP, distant FFP, median survival, overall survival (OS), and toxicity.

Results

The median follow-up was 19.3 months (range 12.89–29.57 months). The median age was 65 years (range 45–84 years). The median size of resected tumor was 2.7 cm (range 1.5–5.5 cm), and the median volume of resected tumor was 10.31 cm3 (range 1.77–87.11 cm3). The median number of seeds used was 12 (range 4–35), with a median activity of 3.82 mCi per seed (range 3.31–4.83 mCi) and total activity of 46.91 mCi (range 15.31–130.70 mCi). Local FFP was 100%. There was 1 adjacent leptomeningeal recurrence, resulting in a 1-year regional FFP of 93.8% (95% CI 63.2%–99.1%). One-year distant FFP was 48.4% (95% CI 26.3%–67.4%). Median OS was 9.9 months (95% CI 4.8 months, upper limit not estimated) and 1-year OS was 50.0% (95% CI 29.1%–67.8%). Complications included CSF leak (1), seizure (1), and infection (1). There was no radiation necrosis.

Conclusions

The use of postresection permanent 131Cs brachytherapy implants resulted in no local recurrences and no radiation necrosis. This treatment was safe, well tolerated, and convenient for patients, resulting in a short radiation treatment course, high response rate, and minimal toxicity. These findings merit further study with a multicenter trial.

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João Paulo Almeida, Armando S. Ruiz-Treviño, Buqing Liang, Sacit B. Omay, Sathwik R. Shetty, Yu-Ning Chen, Vijay K. Anand, Kartikey Grover, Paul Christos and Theodore H. Schwartz

OBJECTIVE

Surgery is generally the first-line therapy for acromegaly. For patients with residual or recurrent tumors, several treatment options exist, including repeat surgery, medical therapy, and radiation. Reoperation for recurrent acromegaly has been associated with poor results, with hormonal control usually achieved in fewer than 50% of cases. Extended endonasal endoscopic approaches (EEAs) may potentially improve the results of reoperation for acromegaly by providing increased visibility and maneuverability in parasellar areas.

METHODS

A database of all patients treated in the authors’ center between July 2004 and February 2016 was reviewed. Cases involving patients with acromegaly secondary to growth hormone (GH)–secreting adenomas who underwent EEA were selected for chart review and divided into 2 groups: first-time surgery and reoperation. Disease control was defined by 2010 guidelines. Clinical and radiological characteristics and outcome data were extracted. A systematic review was done through a MEDLINE database search (2000–2016) to identify studies on the surgical treatment of acromegaly. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the included studies were reviewed for surgical approach, tumor size, cavernous sinus invasion, disease control, and complications. Cases were divided into reoperation or first-time surgery for comparative analysis.

RESULTS

A total of 44 patients from the authors’ institution were included in this study. Of these patients, 2 underwent both first-time surgery and reoperation during the study period and were therefore included in both groups. Thus data from 46 surgical cases were analyzed (35 first-time operations and 11 reoperations). The mean length of follow-up was 70 months (range 6–150 months). The mean size of the reoperated tumors was 14.8 ± 10.0 mm (5 micro- and 6 macroadenomas). The patients’ mean age at the time of surgery was younger in the reoperation group than in the first-time surgery group (34.3 ± 12.8 years vs 49.1 ± 15.7 years, p = 0.007) and the mean preoperative GH level was also lower (7.7 ± 13.1 μg/L vs 25.6 ± 36.8 μg/L, p = 0.04). There was no statistically significant difference in disease control rates between the reoperation (7 [63.6%] of 11) and first-time surgery (25 [71.4%] of 33) groups (p = 0.71). Univariate analysis showed that older age, smaller tumor size, lower preoperative GH level, lower preoperative IGF-I level, and absence of cavernous sinus invasion were associated with higher chances of disease control in the first-time surgery group, whereas only absence of cavernous sinus invasion was associated with disease control in the reoperation group (p = 0.01). There was 1 case (9%) of transient diabetes insipidus and hypogonadism and 1 (9%) postoperative nasal infection after reoperation. The systematic review retrieved 29 papers with 161 reoperation and 2189 first-time surgery cases. Overall disease control for reoperation was 46.8% (95% CI 20%–74%) versus 56.4% (95% CI 49%–63%) for first-time operation. Reoperation and first-time surgery had similar control rates for microadenomas (73.6% [95% CI 32%–98%] vs 77.6% [95% CI 68%–85%]); however, reoperation was associated with substantially lower control rates for macroadenomas (27.5% [95% CI 5%–57%] vs 54.3% [95% CI 45%–62%]) and tumors invading the cavernous sinus (14.7% [95% CI 4%–29%] vs 38.5% [95% CI 27%–50%]).

CONCLUSIONS

Reoperative EEA for acromegaly had results similar to those for first-time surgery and rates of control for macroadenomas that were better than historical rates. Cavernous sinus invasion continues to be a negative prognostic indicator for disease control; however, results with EEA show improvement compared with results reported in the prior literature.