Authors of this report describe a Fukushima Type D(b) or Kawase Type ME2 trigeminal schwannoma involving the right maxillary division in a 59-year-old woman who presented with intermittent right-sided facial numbness and pain. This tumor was successfully resected via a right lateral orbitotomy without the need for craniotomy. This novel approach to a lesion of this type has not yet been described in the scientific literature. The outcome in this case was good, and the patient's intra- and postoperative courses proceeded without complication. The epidemiology of trigeminal schwannomas and some technical aspects of lateral orbitotomy, including potential advantages of this approach over traditional transcranial as well as fully endoscopic dissections in appropriately selected cases, are also briefly discussed.
Scott A. Wallace, R. Michael Meyer, Michael J. Cirivello, and Raymond I. Cho
Fredric B. Meyer, Thoralf M. Sundt Jr., Nicolee C. Fode, Michael K. Morgan, Glen S. Forbes, and James F. Mellinger
✓ In this study, 24 aneurysms occurring in 23 patients under the age of 18 years (mean 12 years) are analyzed. The male:female ratio was 2.8:1, and the youngest patient was 3 months old. Mycotic lesions and those associated with other vascular malformations were excluded. Forty-two percent of the aneurysms were located in the posterior circulation, and 54% were giant aneurysms. Presenting symptoms included subarachnoid hemorrhage in 13 and mass effect in 11. Several of these aneurysms were documented to rapidly increase in size over a 3-month to 2-year period of observation. All aneurysms were surgically treated: direct clipping was performed in 14; trapping with bypass in four; trapping alone in four; and direct excision with end-to-end anastomosis in two. The postoperative results were excellent in 21 aneurysms (87%), good in two (8%), and poor in one. The pathogenesis of cerebral aneurysms is reviewed.
Wouter I. Schievink, Michael R. Puumala, Fredric B. Meyer, Corey Raffel, Jerry A. Katzmann, and Joseph E. Parisi
✓ Recent studies have suggested that a deficiency of α1-antitrypsin may be a genetic risk factor for the development of intracranial aneurysms and arterial fibromuscular dysplasia. The authors report a 16-year-old girl with a history of lung disease who suffered a cerebral hemorrhage due to the rupture of a giant intracranial aneurysm arising from the middle cerebral artery. This fusiform aneurysm was associated with fibromuscular dysplasia of the intimal type. She was found to have an unusual α1-antitrypsin deficiency (PiMP phenotype). This case provides further evidence of an underlying arteriopathy in α1-antitrypsin deficiency.
M. Benjamin Larkin, Erin K. M. Graves, Jason H. Boulter, Nicholas S. Szuflita, R. Michael Meyer, Michael E. Porambo, John J. Delaney, and Randy S. Bell
There are limited data concerning the long-term functional outcomes of patients with penetrating brain injury. Reports from civilian cohorts are small because of the high reported mortality rates (as high as 90%). Data from military populations suggest a better prognosis for penetrating brain injury, but previous reports are hampered by analyses that exclude the point of injury. The purpose of this study was to provide a description of the long-term functional outcomes of those who sustain a combat-related penetrating brain injury (from the initial point of injury to 24 months afterward).
This study is a retrospective review of cases of penetrating brain injury in patients who presented to the Role 3 Multinational Medical Unit at Kandahar Airfield, Afghanistan, from January 2010 to March 2013. The primary outcome of interest was Glasgow Outcome Scale (GOS) score at 6, 12, and 24 months from date of injury.
A total of 908 cases required neurosurgical consultation during the study period, and 80 of these cases involved US service members with penetrating brain injury. The mean admission Glasgow Coma Scale (GCS) score was 8.5 (SD 5.56), and the mean admission Injury Severity Score (ISS) was 26.6 (SD 10.2). The GOS score for the cohort trended toward improvement at each time point (3.6 at 6 months, 3.96 at 24 months, p > 0.05). In subgroup analysis, admission GCS score ≤ 5, gunshot wound as the injury mechanism, admission ISS ≥ 26, and brain herniation on admission CT head were all associated with worse GOS scores at all time points. Excluding those who died, functional improvement occurred regardless of admission GCS score (p < 0.05). The overall mortality rate for the cohort was 21%.
Good functional outcomes were achieved in this population of severe penetrating brain injury in those who survived their initial resuscitation. The mortality rate was lower than observed in civilian cohorts.
Isaac Josh Abecassis, Christopher C. Young, David J. Caldwell, Abdullah H. Feroze, John R. Williams, R. Michael Meyer, Ryan T. Kellogg, Robert H. Bonow, and Randall M. Chesnut
Decompressive craniectomy (DC) is an effective, lifesaving option for reducing intracranial pressure (ICP) in traumatic brain injury (TBI), stroke, and other pathologies with elevated ICP. Most DCs are performed via a standard trauma flap shaped like a reverse question mark (RQM), which requires sacrificing the occipital and posterior auricular arteries and can be complicated by wound dehiscence and infections. The Ludwig Kempe hemispherectomy incision (Kempe) entails a T-shaped incision, one limb from the midline behind the hairline to the inion and the other limb from the root of the zygoma to the coronal suture. The authors’ objective in this study was to define their implementation of the Kempe incision for DC and craniotomy, report clinical outcomes, and quantify the volume of bone removed compared with the RQM incision.
A retrospective review of a single-surgeon experience with DC in TBI and stroke was performed. Patient demographics, imaging, and outcomes were collected for all DCs from 2015 to 2020, and the incisions were categorized as either Kempe or RQM. Preoperative and postoperative CT scans were obtained and processed using a combination of automatic segmentation (in Python and SimpleITK) with manual cleanup and further subselection in ITK-SNAP. The volume of bone removed was quantified, and the primary outcome was percentage of hemicranium removed. Postoperative surgical wound infections, estimated blood loss (EBL), and length of surgery were compared between the two groups as secondary outcomes. Cranioplasty data were collected.
One hundred thirty-six patients were included in the analysis; there were 57 patients in the craniotomy group (44 patients with RQM incisions and 13 with Kempe incisions) and 79 in the craniectomy group (41 patients with RQM incisions and 38 Kempe incisions). The mean follow-up for the entire cohort was 251 ± 368 days. There was a difference in the amount of decompression between approaches in multivariate modeling (39% ± 11% of the hemicranium was removed via the Kempe incision vs 34% ± 10% via the RQM incision, p = 0.047), although this did not achieve significance in multivariate modeling. Wound infection rates, EBL, and length of surgery were comparable between the two incision types. No wound infections in either cohort were due to wound dehiscence. Cranioplasty outcomes were comparable between the two incision types.
The Kempe incision for craniectomy or craniotomy is a safe, feasible, and effective alternative to the RQM. The authors advocate the Kempe incision in cases in which contralateral operative pathology or subsequent craniofacial/skull base repair is anticipated.
Brian Y. Hwang, Samuel S. Bruce, Geoffrey Appelboom, Matthew A. Piazza, Amanda M. Carpenter, Paul R. Gigante, Christopher P. Kellner, Andrew F. Ducruet, Michael A. Kellner, Rajeev Deb-Sen, Kerry A. Vaughan, Philip M. Meyers, and E. Sander Connolly Jr.
Intraventricular hemorrhage (IVH) associated with intracerebral hemorrhage (ICH) is an independent predictor of poor outcome. Clinical methods for evaluating IVH, however, are not well established. This study sought to determine the best IVH grading scale by evaluating the predictive accuracies of IVH, Graeb, and LeRoux scores in an independent cohort of ICH patients with IVH. Subacute IVH dynamics as well as the impact of external ventricular drain (EVD) placement on IVH and outcome were also investigated.
A consecutive cohort of 142 primary ICH patients with IVH was admitted to Columbia University Medical Center between February 2009 and February 2011. Baseline demographics, clinical presentation, and hospital course were prospectively recorded. Admission CT scans performed within 24 hours of onset were reviewed for ICH location, hematoma volume, and presence of IVH. Intraventricular hemorrhage was categorized according to IVH, Graeb, and LeRoux scores. For each patient, the last scan performed within 6 days of ictus was similarly evaluated. Outcomes at discharge were assessed using the modified Rankin Scale (mRS). Receiver operating characteristic analysis was used to determine the predictive accuracies of the grading scales for poor outcome (mRS score ≥ 3).
Seventy-three primary ICH patients (51%) had IVH. Median admission IVH, Graeb, and LeRoux scores were 13, 6, and 8, respectively. Median IVH, Graeb and LeRoux scores decreased to 9 (p = 0.005), 4 (p = 0.002), and 4 (p = 0.003), respectively, within 6 days of ictus. Poor outcome was noted in 55 patients (75%). Areas under the receiver operating characteristic curve were similar among the IVH, Graeb, and LeRoux scores (0.745, 0.743, and 0.744, respectively) and within 6 days postictus (0.765, 0.722, 0.723, respectively). Moreover, the IVH, Graeb, and LeRoux scores had similar maximum Youden Indices both at admission (0.515 vs 0.477 vs 0.440, respectively) and within 6 days postictus (0.515 vs 0.339 vs 0.365, respectively). Patients who received EVDs had higher mean IVH volumes (23 ± 26 ml vs 9 ± 11 ml, p = 0.003) and increased incidence of Glasgow Coma Scale scores < 8 (67% vs 38%, p = 0.015) and hydrocephalus (82% vs 50%, p = 0.004) at admission but had similar outcome as those who did not receive an EVD.
The IVH, Graeb, and LeRoux scores predict outcome well with similarly good accuracy in ICH patients with IVH when assessed at admission and within 6 days after hemorrhage. Therefore, any of one of the scores would be equally useful for assessing IVH severity and risk-stratifying ICH patients with regard to outcome. These results suggest that EVD placement may be beneficial for patients with severe IVH, who have particularly poor prognosis at admission, but a randomized clinical trial is needed to conclusively demonstrate its therapeutic value.
R. Michael Meyer, M. Benjamin Larkin, Nicholas S. Szuflita, Chris J. Neal, Jeffrey M. Tomlin, Rocco A. Armonda, Jeffrey A. Bailey, and Randy S. Bell
Traumatic brain injury (TBI) is independently associated with deep vein thrombosis (DVT) and pulmonary embolism (PE). Given the numerous studies of civilian closed-head injury, the Brain Trauma Foundation recommends venous thromboembolism chemoprophylaxis (VTC) after severe TBI. No studies have specifically examined this practice in penetrating brain injury (PBI). Therefore, the authors examined the safety and effectiveness of early VTC after PBI with respect to worsening intracranial hemorrhage and DVT or PE.
The Kandahar Airfield neurosurgery service managed 908 consults between January 2010 and March 2013. Eighty of these were US active duty members with PBI, 13 of whom were excluded from analysis because they presented with frankly nonsurvivable CNS injury or they died during initial resuscitation. This is a retrospective analysis of the remaining 67 patients.
Thirty-two patients received early VTC and 35 did not. Mean time to the first dose was 24 hours. Fifty-two patients had blast-related PBI and 15 had gunshot wounds (GSWs) to the head. The incidence of worsened intracranial hemorrhage was 16% after early VTC and 17% when it was not given, with the relative risk approaching 1 (RR = 0.91). The incidence of DVT or PE was 12% after early VTC and 17% when it was not given (RR = 0.73), though this difference was not statistically significant.
Early VTC was safe with regard to the progression of intracranial hemorrhage in this cohort of combat-related PBI patients. Data in this study suggest that this intervention may have been effective for the prevention of DVT or PE but not statistically significantly so. More research is needed to clarify the safety and efficacy of this practice.
Robert F. James, Nicolas K. Khattar, Zaid S. Aljuboori, Paul S. Page, Elaine Y. Shao, Lacey M. Carter, Kimberly S. Meyer, Michael W. Daniels, John Craycroft, John R. Gaughen Jr., M. Imran Chaudry, Shesh N. Rai, D. Erik Everhart, and J. Marc Simard
Cognitive dysfunction occurs in up to 70% of aneurysmal subarachnoid hemorrhage (aSAH) survivors. Low-dose intravenous heparin (LDIVH) infusion using the Maryland protocol was recently shown to reduce clinical vasospasm and vasospasm-related infarction. In this study, the Montreal Cognitive Assessment (MoCA) was used to evaluate cognitive changes in aSAH patients treated with the Maryland LDIVH protocol compared with controls.
A retrospective analysis of all patients treated for aSAH between July 2009 and April 2014 was conducted. Beginning in 2012, aSAH patients were treated with LDIVH in the postprocedural period. The MoCA was administered to all aSAH survivors prospectively during routine follow-up visits, at least 3 months after aSAH, by trained staff blinded to treatment status. Mean MoCA scores were compared between groups, and regression analyses were performed for relevant factors.
No significant differences in baseline characteristics were observed between groups. The mean MoCA score for the LDIVH group (n = 25) was 26.4 compared with 22.7 in controls (n = 22) (p = 0.013). Serious cognitive impairment (MoCA ≤ 20) was observed in 32% of controls compared with 0% in the LDIVH group (p = 0.008). Linear regression analysis demonstrated that only LDIVH was associated with a positive influence on MoCA scores (β = 3.68, p =0.019), whereas anterior communicating artery aneurysms and fevers were negatively associated with MoCA scores. Multivariable linear regression analysis resulted in all 3 factors maintaining significance. There were no treatment complications.
This preliminary study suggests that the Maryland LDIVH protocol may improve cognitive outcomes in aSAH patients. A randomized controlled trial is needed to determine the safety and potential benefit of unfractionated heparin in aSAH patients.
Cecilia L. Dalle Ore, Stephen T. Magill, Adam J. Yen, Maryam N. Shahin, David S. Lee, Calixto-Hope G. Lucas, William C. Chen, Jennifer A. Viner, Manish K. Aghi, Philip V. Theodosopoulos, David R. Raleigh, Javier E. Villanueva-Meyer, and Michael W. McDermott
Extracranial meningioma metastases are uncommon, occurring in less than 1% of patients diagnosed with meningioma. Due to the rarity of meningioma metastases, patients are not routinely screened for distant disease. In this series, we report their experience with meningioma metastases and results of screening for metastases in select patients with recurrent meningiomas.
All patients undergoing resection or stereotactic radiosurgery for primary or recurrent meningioma from 2009 to 2017 at a single center were retrospectively reviewed to identify patients who were diagnosed with or underwent imaging to evaluate for systemic metastases. Imaging to evaluate for metastases was performed with CT scanning of the chest, abdomen, and pelvis or whole-body PET/CT using either FDG or 68Ga-DOTA-octreotate (DOTATATE) tracers in 28 patients. Indications for imaging were symptomatic lesions concerning for metastasis or asymptomatic screening in patients with greater than 2 recurrences being evaluated for additional treatment.
Of 1193 patients treated for meningioma, 922 (77.3%) patients had confirmed or presumed WHO grade I tumors, 236 (19.8%) had grade II tumors, and 35 (2.9%) had grade III tumors. Mean follow-up was 4.3 years. A total of 207 patients experienced recurrences (17.4%), with a mean of 1.8 recurrences. Imaging for metastases was performed in 28 patients; 1 metastasis was grade I (3.6%), 16 were grade II (57.1%), and 11 were grade III (39.3%). Five patients (17.9%) underwent imaging because of symptomatic lesions. Of the 28 patients screened, 27 patients had prior recurrent meningioma (96.4%), with a median of 3 recurrences. On imaging, 10 patients had extracranial lesions suspicious for metastasis (35.7%). At biopsy, 8 were meningioma metastases, 1 was a nonmeningioma malignancy, and 1 patient was lost to follow-up prior to biopsy. Biopsy-confirmed metastases occurred in the liver (5), lung (3), mediastinum (1), and bone (1). The observed incidence of metastases was 0.67% (n = 8). Incidence increased to 2% of WHO grade II and 8.6% of grade III meningiomas. Using the proposed indications for screening, the number needed to screen to identify one patient with biopsy-confirmed malignancy was 3.83.
Systemic imaging of patients with multiply recurrent meningioma or symptoms concerning for metastasis may identify extracranial metastases in a significant proportion of patients and can inform decision making for additional treatments.