Subject: Tumor
Title: Cerebral revascularization and carotid resection at the skull base for treatment of advanced head and neck malignancies
Authors: Yashar Kalani; Iman Feiz-Erfan; Robert F spetzler; Porter Randall; Sammy Kalb; Nikolay Maritrosyan; S Lettieri
Introduction: Resection of cancer and the involved artery in the neck has been applied with some success, but the indications for such an aggressive approach at the skull base are less well defined.
Methods: We retrospectively reviewed the charts of all patients with advanced head and neck cancers who underwent ICA sacrifice with revascularization using extracranial-to-intracranial bypass between 1995 and 2010 at our Institute.
Results: Eighteen patients (11 males; 7 females; mean age 46 years) were identified. There were 4 sarcomas and 14 carcinomas that involved the ICA at the skull base. All patients underwent ICA sacrifice with revascularization. One patient died from a stroke after revascularization. A second patient died from consequences of a fistula between the oral and cranial cavities (surgical mortality rate 11.1%). Eight months after the operation, one patient developed occlusion of the bypass and died. Complications associated with the bypass surgery included one case of subdural hematoma with blindness, one case of status epilepticus, and one case of asymptomatic bypass occlusion (bypass morbidity 16.7%). Complications associated with tumor resection included three cases of CSF leakage requiring repair and shunting, one case of hydrocephalus requiring shunting, one case of subdural hematoma, and one case of contralateral ICA injury requiring a bypass (tumor resection morbidity rate 33.3%). In one patient treated with adjuvant therapy before surgery, we identified only radiation effect. In a second patient, the bypass was occluded and his tumor was not resected. The other 16 patients underwent gross total resection of their tumor. Excluding the surgical deaths, the mean and median length of survival series was 13.2 and 8.3 months, respectively (range 1.5-48 months). Including the surgical deaths, the mean and median length of survival was 11.8 and 8 months, respectively (range 17 days-48 months).
Conclusions: Despite maximal surgical intervention, including ICA sacrifice at the skull base with revascularization, patient survival was dismal and the complication rate was significant. We no longer advocate such an aggressive approach in this patient population. On a rare occasion, however, such an approach may be considered for low-grade malignancies.
Keywords: skull base, malignant, bypass, carotid-sacrifice
Objectives: Discuss indications for and outcomes of carotid sacrifice and bypass in the setting of advanced head and neck malignancies.
Subject: Cerebrovascular
Title: Submandibular High-Flow Bypass in the Treatment of Skull Base Lesions: Long-Term Outcome
Authors: Walavan Sivakumar; William Couldwell; Philipp Taussky
Introduction: Extracranial-intracranial bypass techniques remain an integral part of the treatment of complex skull base tumors and unclippable aneurysms. Specifically, giant and fusiform aneurysms that are amenable to neither clipping nor endovascular treatment may require proximal vessel occlusion and a bypass procedure for revascularization purposes. Skull base tumors involving the carotid artery may be treated with the goal of gross total resection by internal carotid artery (ICA) sacrifice. In these instances, an extracranialñintracranial bypass offers revascularization of the distal vascular tree. Previous bypass techniques have predominantly required subcutaneous tunneling of the vein graft, thereby impacting long-term bypass patency. The senior author previously described a direct submandibular-infratemporal bypass technique that eliminates the need for tunneling.
Methods: The investigators retrospectively analyzed a single-surgeon experience using a high-flow submandibularñinfratemporal saphenous vein graft bypass technique after carotid artery sacrifice in the resection of complex skull base tumors and carotid isolation in unclippable aneurysms. Data on indications, surgical technique, bypass patency, complications, and outcome were collected for patients treated with adjunctive submandibular high-flow bypass for skull base lesions.
Results: Eleven patients (age range: 13ñ77 years) were treated for various skull base lesions: 4 patients were treated for skull base tumors with resection of the ICA, 6 were treated for aneurysms not amenable to clipping, and one was treated for invasive Mucor infection. Using a saphenous vein graft, a high-flow bypass was created from the high cervical internal carotid artery (ICA) or external carotid artery to ICA or middle cerebral artery by means of a submandibularñinfratemporal route. Postoperative computed tomography angiography indicated bypass patency in 10/11 patients. There was no operative mortality. Follow-up of up to 12 years (mean 57 months) was achieved.
Conclusions: Direct high-flow submandibularñinfratemporal interpositional saphenous vein bypass graft is an effective and durable technique for the treatment of complex skull base lesions where internal carotid artery revascularization is indicated.
Keywords: Extracranial-intracranial bypass, carotid artery, saphenous vein, radial artery
Objectives: Understand indications for bypass in treatment of skull base lesions. Understand the advantages/disadvantages to preauricular and postauricular tunneling. Understand the advantages/disadvantages of the novel submandibular infratemporal approach to bypass method.
Subject: Pediatrics
Title: Factors and Rates of Pediatric Bone Flap Resorption after Decompressive Craniectomy for Severe Traumatic Brain Injury
Authors: Christian A. Bowers; Jay Riva-Cambrin; Marion L Walker
Introduction: Decompressive craniectomy (DC) for pediatric traumatic brain injury (TBI) is commonly performed. Bone flap resorption (BFR) after autologous cranioplasty (AC) is morbid, requiring additional surgery. There is almost no documentation of pediatric BFR following TBI and there are no known risk factors.
Methods: We performed a retrospective chart cohort review for long-term survivors that underwent DC for severe TBI from 1996 to 2010. We looked at multiple variables: Age, sex, mechanism, GCS, Rotterdam score, comminuted skull fracture (SF), post-traumatic hydrocephalus (PTH), infection, permanent VPS, time to AC and/or BFR. We analyzed these variables using bivariate statistical fashion and a multivariate logistic regression model for significant variables.
Results: We found that 50.9% of our sample patients experienced BFR. The average sample age was 6.25 years. The mean time to AC was 2.06 months and the mean time for BFR was 9.52 months. Univariate comparisons were made between a number of baseline variables and outcome of BFR. Significant associations were observed with SF, infection, PTH, and a permanent VPS. Eighty-one percent (13/16) of patients with comminuted skull fractures, 80% requiring permanent VPS, 88.9% with post-operative infection, and 90% with hydrocephalus after AC had BFR. No other factors were significant. We then used multivariate analysis to develop a predictive model (logistic regression, forward, conditional). The variables entered were comminuted skull fractures, permanent VPS, and age <2.5. Comminuted skull fractures (O.R. 10.94, CI (1.19, 100.7), p=0.03), permanent VPS (O.R. 34.4, CI (2.56, 4626), p=0.007), and age < 2.5 years old (O.R. 36.1, CI (3.07, 474.5), p=0.005) were found to be significant risk factors for BFR.
Conclusions: After DC for pediatric TBI, a very large percentage [50.9%] of our AC patients experienced BFR. Factors associated with BFR in a multivariate model were patients with permanent VPS, comminuted skull fractures, and age <2.5. This is the largest series of pediatric BFR after craniectomy for TBI and the only one to find risk factors other than size associated with BFR.
Keywords: Craniectomy, TBI, Pediatrics, Cranioplasty
Objectives: 1- Know the reported Bone Flap Resorption rates after autologous cranioplasty in pediatric patients who underwent decompressive craniectomy for severe TBI. 2- Identify the risk factors that have been demonstrated to lead to increased rates of bone flap resorption. 3- Summarize what the previous literature showed concerning pediatric bone flap resorption rates and explain how this new research provides information that can be used to help council patients and their families about autologous cranioplasty success following severe TBI in pediatric patients.
Subject: Pain
Title: New perspectives in diagnosis and management of post operative headache and facial pain
Authors: Steven J Wilk
Introduction: Pre and post operative headache and facial pain can often originate and be perpetuated in the masticatory system. From intubation through discharge, a residual headache can often be managed with appropriate therapies. Dr. Wilk will discuss common causes of these pain entities often overlooked, and discuss management using interventional injections, medication, and oral device therapy.
Methods: Masticatory muscles such as the temporal, massetter, and lateral pterygoid muscles are often injured during surgical procedures. The TMJ apparatus can also be hyper-extended during a difficult intubation. The results of these necessary procedures is often post operative headache, facial, and jaw pain. Symptomatic patients were evaluated in a private clinic following professional referral. Using imaging and anesthetic blockade, a diagnosis and subsequent treatment plan was formulated. Treatment consisted of interventional injections with corticosteroids, onabotulinumtoxinA, and other medicament’s. Oral device therapy was also used to manage patients with movement disorders such as sleep bruxism.
Results: Once the source of headache and facial pain were identified, the patients were treated with an appropriate combination of injections,medications, and oral device therapy.
Conclusions: Post operative headache, facial pain, TM and sleep disorders are frequently seen. Management of neuromuscular pain can be helpful for many patients.
Keywords: Headache, post operative, temporalis, TMD
Objectives: Participants should be able to recognize common headache patterns that will respond to conservative management.
Subject: Tumor
Title: Predicting outcomes of patient with oligodendrogliomas: Comparison of IDH-1, 1p19q, hypoxia biomarkers, and preoperative patient characteristics and imaging.
Authors: Randy L. Jensen; Nan Hu
Introduction: We examine whether traditional tumor measures such as MIB-1 proliferation index (PI), microvascular density (MVD index),1p19q chromosomal co-deletion or the emerging biomarker isocitrate dehydrogenase isoform 1 (IDH-1) and molecular markers of hypoxia including hypoxia-inducible factor-1α (HIF-1α) and its downstream targets vascular endothelial growth factor (VEGF), glucose transporter-1 (GLUT-1), and carbonic anhydrase-IX (CA-IX) , and the UCSF preoperative grading system are able to predict progression-free (PFS) and overall (OS) survival of oligodendroglioma.
Methods: We prospectively collected tissue samples and followed outcomes of 50 patients with oligodendrogliomas and 32 with anaplastic oligodendrogliomas (AO). We retrospectively analyzed preoperative imaging and clinical data based on the UCSF scoring system (good prognostic indicators: Karnofsky Performance Scale (KPS) score>80, age<50 years, tumor diameter<4 cm, noneloquent tumor location) and correlated this with immunohistochemical markers, 1p19q chromosomal status, and compared both with patient PFS and OS.
Results: Mean follow-up was 88 months. 1p19q codeletion was associated with a better overall survival for both oligodendrogliomas (p=0.011) and AO (p=0.077). IDH-1 mutation was associated with better OS for both oligodendrogliomas (p=0.033) and AOs (p=0.050). 1p19q codeletion also predicted higher PFS for both oligodendrogliomas (p=0.049) and AOs (p=0.045). IDH-1 mutation was also associated with increased PFS for both oligodendrogliomas (p=0.062) and AOs (p=0.021). Higher MIB-1 correlated with worse OS in oligodendrogliomas (p=0.015) and higher GLUT-1 expression is associated with worse PFS in AO (p=0.019). We also evaluated the performance of the these markers using C-statistics and found UCSF and both IDH-1 and 1p/19q deletion status accurate in predicting both OS and PFS events. GLUT-1 appears to be as good as the UCSF score in predicting PFS.
Conclusions: 1p19q deletion and IDH-1 mutation are the most accurate predictor of patient outcome for oligodendrogliomas. The UCSF score, MIB-1 and GLUT-1 are also useful. The small sample size of patients and the retrospective nature of this study is major limitations of our report. Further studies are warranted to validate our interesting results in larger patient populations.
Keywords: anaplastic, isocitrate, hypoxia, chromosomal, outcome
Objectives: 1. Describe preoperative patient characteristics that can predict patient outcome with oligodendrogliomas 2. Understand molecular markers that can may be used to determine patient progression free survival and overall survival in patients with oligodendrogliomas 3. Utilize IDH-1 and 1p19q gene mutation information for predicting behavior of oligodendroglioma tumors.
Subject: Tumor
Title: Planning, implementation, construction and preliminary use of a combination diagnostic and intraoperative magnetic resonance imaging system at the University of Utah.
Authors: Randy L. Jensen
Introduction: We have recently begun using an intraoperative magnetic resonance imaging (IMRI) system at the Huntsman Cancer Institute (HCI) at the University of Utah. A second, IMRI system with both intraoperative and interventional angiographic capability is currently under construction. This report describes the critical decisions, planning, construction, and use of this system.
Methods: We have now used the HCI system for over 25 cases. We have prospectively collected patient information including demographics, surgical procedure including the use of awake cortical mapping and navigation systems. Complications and pitfalls were recorded.
Results: These cases were all tumor cases, mostly for low-grade gliomas. Only one case had technical difficulties requiring the procedure to be done without intraoperative MRI. Intraoperative MRI fusion and navigation was seamless. There were no complications but there was one potential near miss with operating table equipment that was recognized before any difficulties occurred. We will discuss the rationale of using this technology and patient selection.
Conclusions: Intraoperative MRI is safe and relatively easy to do. The clinical utility and impact on patient outcome is yet to be proven. We discuss patient selection and future applications of this technology
Keywords: Intraoperative MRI, navigation, IMRIS
Objectives: 1. Discuss the use of intraoperative MRI for brain tumor surgery 2. Understand the limitations of intraoperative MRI 3. Describe the rationale and indications for intraoperative MRI for
Subject: Tumor
Title: Differential Scanning Calorimetry of Cerebrospinal Fluid, Brain Tumor Cells Lines, and Patient Tumor Samples: Emphasis on correlation with tumor diagnosis and histology
Authors: Randy L. Jensen
Introduction: Thermal stability signatures of complex molecule interaction in biological fluids can be measured using a new approach called differential scanning calorimetry (DSC). The thermal stability of plasma proteome has been described previously as a method of producing a disease-specific ìsignature,î termed thermogram, in several neoplastic and autoimmune diseases. We describe the preliminary use of DSC performed on cerebrospinal fluid (CSF) brain tumor cell cultures and human brain tumor tissue samples to create unique thermograms for correlation with histological tumor classification.
Methods: Samples of CSF from nine patients with confirmed GBM were evaluated using DSC, and the thermogram signatures evaluated. These thermograms were compared with thermograms of CSF taken from patients with non-neoplastic conditions such as head trauma, hydrocephalus, or CSF leak. Further analysis was also performed on CSF from patients who had non-GBM neoplastic conditions such as carcinomatosis meningitis or central nervous system lymphoma or leukemia. With these established techniques we then used the same technique to examine cell lines (3 GBM and 2 meningioma) and brain tumor tissue samples (10 GBM, 5 oligodendrogliomas, 5 low grade astrocytomas, and 10 meningiomas) with confirmed histological diagnosis.
Results: The DSC thermograms of CSF of the patients with GBM were significantly different when compared with other neoplastic and nonneoplastic cases. The melting temperature of the major transition was shifted by 5∞C, which makes it easily distinguishable from control cases. DSC profiles of glioma and meningioma cell lines are distinctly different. Brain tumor sample analysis correlates with the cell line work with distinct GBM, oligodendroglioma, low-grade astrocytoma, and meningioma ìsignaturesî
Conclusions: Our results are very preliminary, but it appears that the DSC of CSF has potential utility in diagnostics and monitoring disease progression in GBM patients. DSC of processed tumor samples seems to display unique ìsignaturesî for different brain tumor histological
Keywords: diagnosis, calorimetry, signatures, tumor profiles
Objectives: 1. Understand the use of DSC for tumor diagnosis 2. Discuss the utility of DSC for determining tissue grade 3. Explain how DSC might be used for CSF diagnosis of brain tumors
Subject: Cerebrovascular
Title: Microsurgical Treatment of Anterior Choroidal Artery Aneurysms: Lessons Learned
Authors: Daniel R Klinger; Gordon Mao; Jonathan A. White
Introduction: Anterior choroidal artery (AChoA) aneurysms represent 2-5% of all intracranial aneurysms. They are supraclinoid lesions often in close proximity to the posterior communicating artery and the carotid bifurcation, and traditionally their treatment has consisted of microsurgical clipping. Despite advancements in endovascular treatment modalities, it remains important and essential to analyze and understand the complexities of microsurgical treatment.
Methods: A retrospective search of a prospectively-maintained patient database from 1990 through 2010 identified patients who underwent microsurgical treatment of AChoA aneurysms. Data collected included patient age and gender, presenting symptoms, aneurysm size and anatomy, presence and location of other aneurysms, surgical complications and patient outcomes.
Results: 79 patients underwent treatment for anterior choroidal artery aneurysms. A total of ten cases were excluded from the evaluation for reasons that included surgical wrapping without clipping (6), insufficient chart data (3) and incorrect documentation of aneurysm location (1): leaving 69 cases involving 67 patients. 57% of patients suffered aneurysmal subarachnoid hemorrhage (SAH): 30% with ruptured AChoA aneurysms and 27% from rupture of another intracranial aneurysm. The rate of transient surgical complication was 17%, and the rate of of permanent neurological complication was 13%, with AChoA infarct the most common complication at 7.2%. There was a significantly higher rate of AChoA infarct in cases of AChoA aneurysm rupture (24% v. 2.1%, p = 0.009). 84% of patients sustained a good outcome (GOS ≥ 4) at 6 months and 83% at 1 year.
Conclusions: The microsurgical treatment of AChoA aneurysms carries significant surgical risk (30%) and a high risk of AChoA infarct (7.2%) that increases significantly in cases of AChoA rupture (24% rate of AChoA infarct). Despite these concerns, the majority of treated patients have the potential for a good functional outcome after surgical intervention.
Keywords: anterior choroidal artery, aneurysm, subarachnoid hemorrhage, microsurgery
Objectives:
Subject: Tumor
Title: 10 year Experience with Surgical Treatment of Spheno-Orbital Meningiomas at the University of Colorado
Authors: Kevin O Lillehei; Oscar Szentirmai
Introduction: Spheno-orbital meningiomas are an unusual subset of skull base meningiomas associated with hyperostosis of the spheno-orbital region, with frequent invasion into the cavernous sinus, optic canal and superior orbital fissure. Patients present with characteristic symptoms of proptosis, visual impairment and ocular paresis. Surgery is often challenging, requiring orbital decompression, sphenoid bone resection, optic nerve decompression and skull base reconstruction. Recurrence rates are associated with extent of resection and tumor histology.
Methods: We reviewed our last 10 year surgical experience at the University of Colorado and identified 25 patients with spheno-orbital meningiomas. Fronto-temporal craniotomy was performed in all patients with an extradural resection of the hyperostotic skull base, extradural lateral orbital decompression and an extradural opening of the optic canal (as indicated). This was followed by an intradural tumor resection. Cranial reconstruction was performed in all cases without the need for specific orbital reconstruction.
Results: 80% of patients were female and 20% male, consistent with prior reports. Our median follow-up was 3 years. Ability to obtain a complete resection was limited by the extent of orbital, superior orbital fissure, and cavernous sinus invasion. In all cases, the spheno-orbital hyperostosis was found secondary to tumor invasion. The CT and MRI features of this unusual tumor will be presented along with the spectrum of pathologic findings. Extent of resection, need for post-operative adjuvant radiation therapy and recurrence rate will also be presented. An analysis of the literature will be presented, highlighting the difference between these tumors and anterior clinoid or planum sphenoidale meningiomas, particularly with respect to optic canal invasion. Intra-operative video recordings will be shown with a discussion of the importance of collaborating with an oculo-plastics surgeon for successful resection of the intra-orbital extension of these tumors.
Conclusions: Spheno-orbital meningiomas are an unusual and challenging subset of tumors requiring both an intra-dural and extra-dural approach. The ability to obtain a gross total resection is dependent on the extent of tumor invasion. We advocate an aggressive skull base resection and in this presentation analyze our outcomes in a series of 25 patients.
Keywords: sphenoorbital meningioma, proptosis, sphenoid wing, optic nerve
Objectives: …understand the relevant anatomy for safe and successful resection of sphenoorbital meningiomas, be able to discuss surgical approaches, understand the literature and discuss management of complications and recurrences.
Subject: Tumor
Title: Survival in patients with metastatic melanoma to the brain
Authors: Oscar Szentirmai; Robert E Breeze
Introduction: With dismal survival rates of 4-6 months in larger series of patients with stage IV melanoma metastases to the brain, even today treatment of such patients is considered by some as futile. Few larger centers accumulated data on improved survival utilizing stereotactic radiosurgery. Treatment options are limited to surgical resection and stereotactic radiosurgery due to lack of intracerebral penetration of chemotherapeutics and radioresistance. Despite overall mortality still approaching 100%, more and more patients can have a significantly longer progression-free survival with better quality of life with close follow-up.
Methods: We reviewed our experience between 1993 and 2009 at the University of Colorado with the treatment of patients with melanoma metastasis to the brain. The patients are followed by the Cancer Center and referred for neurosurgical evaluation as soon as a diagnosis of cerebral metastasis is made. A single neurosurgeon (REB) determines if the patient is offered surgery and/or stereotactic radiosurgery. Patients are followed every 6 weeks with repeat brain MRI scans to determine the need for further treatments. SRS is delivered to all patients using an Elekta Gamma Knife unit.
Results: 163 patients were enrolled in this review with 1 excluded. A total of 1051 brain metastasis were treated in 163 patients. Median age was 56.1 years, 66% were males and 34% were femailes. An average of 6.6 metastasis were treated in each patient, and an average of 3 metastasis were treated during initial SRS. 56% of metastasis were located in or near eloquent brain, 40% of them in the frontal lobe. Median survival in this group was 8.6 months with only 4.3% of patients receiving whole brain radiation therapy.
Conclusions: With close follow-up and combined surgical and radiosurgical management of patients with melanoma brain metastasis, better survival can be achieved without WBRT than has been reported before.
Keywords: melanoma, brain metastasis, gamma knife, surgery
Objectives: understand the prevalence of melanoma brain metastasis understand the implications of early and aggressive surgical and radiosurgical management of these patients understand the literature on dismal survival rates in this population understand the change in approach to treatment in this population resulting in better quality of life and survival
Subject: Tumor
Title: Frontoethmoid osteoma with pneumocephalus: Case report and consideration of options for surgical management
Authors: Yasuaki Harasaki; Kelly J. Pettijohn; Allen Waziri; Vijay Ramakrishnan
Introduction: Pneumocephalus has been reported as an exceedingly rare complication of frontoethmoid osteomas. The overarching surgical strategy for affected patients remains undefined.
Methods: We describe the case of a 61 year old female who presented with frontal sinus osteoma accompanied by profound intraparenchymal pneumocephalus and associated neurological deficit, treated through a minimally-invasive combined surgical strategy involving image-guided burr hole decompression of the pneumocephalus followed by transnasal endoscopic removal of the tumor. Using this approach, the patient rapidly recovered full neurological function. We review the details of our management strategy in the context of previously reported cases.
Results: Although there have been suggestions in existing literature of the rarity of intraparenchymal pneumocephalus associated with frontoethmoid osteomas, review of existing literature reveals that pneumocephalus is most commonly reported as intraprenchymal in these cases. We advocate aggressive management strategy of these lesions through a minimally invasive combined craniofacial approach.
Conclusions: Pneumocephalus when associated with frontoethmoid osteomas are most commonly reported to be intraparenchymal. A combined craniofacial operative approach is minimally invasive while providing excellent surgical access to these lesions. Urgent surgical management is critical due to potential of acute neurologic decompsensation.
Keywords: osteoma, pneumocephalus
Objectives:
Subject: Spine
Title: How did our patients do with lumbar decompression without fusion? A retrospective survey review of the VA population.
Authors: Yasuaki Harasaki; Oscar Szentirmai; Glenn Kindt
Introduction: Lower back pain is one of the most common patient complaints in the United States. Some reports suggest that it may affect 80% of the adult population at some point in their lives. These patients constitute a major part of our neurosurgical practice at the Denver Veterans Administration Hospital. Most of these cases (>95% at 1 year) are initially managed with conservative therapy alone. This leaves a small percentage of patients who require surgical intervention. A portion of those that require surgery have lumbar stenosis.In response to the recently published guidelines and the national trend of increasing spinal fusions for lumbar stenosis, we venture to produce a follow-up study to our 1999 manuscript.
Methods: We hypothesize that good functional outcomes with low incidence of spinal instability can be achieved in treating lumbar stenosis with bilateral partial laminectomy without fusion, saving comorbidities for patients and health care dollars at the same time. We mailed an outcome survery to 400 patients (100/5 years block) whose surgery was performed between 1990 and 2010. The survey included the same questionnaire we used in our 1999 publication and the Oswestry Low Back Pain Disability Index. We anticipated at best a ~50% response rate.
Results: We received 158 survey responses (39.5% response rate). We suspect a significant portion of the non-responders have expired since surgery. We will present the results from the survey quesionnaire, such as “Are you generally satisfied with your surgery?” with 141/158 (89%) responding “Yes” and 11% of responding “no”. Despite this very high satisfaction with surgery overall, when prompted with more specific questions, such as “How is the pain down your legs since you had surgery?”, the mean response was “Somewhat better”. We will review the limitations of such long-term follow-up survery study and it’s implications.
Conclusions: We reviewed our 20 year experience of lumbar decompressions with bilateral partial laminectomies for lumbar stenosis at the Denver Veterans Administration Hospital. We present the results of a survery study and the lack of evidence of spinal instability requiring fusion following bilateral partial laminectomies for decompression in patients with lumbar spinal stenosis.
Keywords: lumbar decompression, laminotomy, lumbar fusion, survey
Objectives: understand the literature on lumbar decompression surgery understand the indications for spinal fusion in patients with lumbar instability review the results of a 20 year follow-up survery study on patients with lumbar decompression for stenosis
Subject: Spine
Title: Microdiscectomy to Minimally Invasive
Authors: Albert H. Capanna
Introduction: The advent of the operating microscope revolutionized neurosurgery totally reversing the inherent morbidity and mortality. Spinal surgery was slow to adopt the microscope and in fact went in the opposite direction with the coming of ìfellowship trainedî orthopedic surgeons. Macrosurgery with fusions of all kinds became the norm- even the ì360 degreeî or anterior/ posterior spinal fusions. Fusions have given way to ìmotion preservationî operations and now to the evolving ìminimally invasiveî spinal fusions. The origin of the microdiscectomy and the evolving direction of spinal surgery will be reviewed.
Methods: Reviewed results of prior surgeries and current morbidity and mortality data.
Results: Minimally invasive reduces morbidity and mortality.
Conclusions: Further evolution of minimally invasive techniques should optimize results while decreasing patient mortality and morbidity.
Keywords: Spine, Microsurgery, Minimally Invasive
Objectives: Learn the direction spinal surgery is going, what is current and what the future may be.
Subject: Trauma
Title: Cranial Reimplantation after Machete Attack
Authors: Albert H. Capanna
Introduction: The patient suffered an assault with a machete with fifteen blows to the head and neck and cutting the fingers off both hands and fracturing the ulna. Multiple cranial comminuted compound skull fractures with cerebellum exuding and the neck opening to the cervical spine. Combined simultaneous emergency procedures of craniectomy, reconstruction of the neck with implantation of the skull and re-implantation of the fingers. The treatment of this complex patient will be reviewed.
Methods: Case study of simultaneous surgery at a Level I Trauma Center.
Results: Combined surgeries in the prone and then supine positions by multiple surgeons allowed salvage of this patient.
Conclusions: The patient had a good result with the multiple specialty trauma team operating emergently.
Keywords: Trauma, Cranial Reimplantation, Machete
Objectives: How to handle a multiple trauma by surgeons of various specialties operating spontaneously.
Subject: Trauma
Title: Recurrent, Delayed Intracranial Hemorrhage associated with Edoxaban and DBS
Authors: Walavan Sivakumar; Sarah T Garber; Paul A. House
Introduction: The previous mainstays of stroke prevention in nonvalvular atrial fibrillation (platelet function inhibition and vitamin K blockade) are being supplanted by direct coagulation factor inhibition. Edoxaban, a novel factor-Xa inhibitor, is currently in phase III clinical trials examining stroke and systemic embolization prevention compared to warfarin.
Methods: The authors report a case of a man who presented with delayed, recurrent intracranial hemorrhage months after successful deep brain stimulator placement for Parkinsonís disease while on edoxaban for atrial fibrillation.
Results: Delayed intracranial hemorrhage is extremely rare following deep brain stimulation. Only a single case of delayed hemorrhage has previously been reported despite approximately 80,000 systems implanted and no cases of recurrent hemorrhage have been described. It is therefore concerning that Edoxaban might carry significant risk of hemorrhage in this setting. The authors will discuss several new direct coagulation factor inhibitors and review the lack of clinical management strategies for caring for patients taking these new medications when intracranial surgery or trauma occur.
Conclusions: This case serves to highlight the limited information available regarding direct coagulation factor inhibitors and intracranial surgery.
Keywords: Anticoagulation, Intracranial Hemorrhage, Trauma
Objectives: …discuss the indications and growing use of novel direct coagulation factor inhibitors. … recognize the need for development of management strategies regarding intracranial hemorrhage for patients treated with these novel medications.
Subject: Trauma
Title: Treatment Considerations For Type II Odontoid Fractures In The Elderly Population
Authors: John B Dietze
Introduction: Type II odontoid fractures are encountered very frequently among the elderly population. Though seldom associated with neurological deficits, these injuries can be quite disabling and their management can be problematic due to the numerous health challenges likely to be present.
Methods: A survey of recent literature was undertaken in order to identify currently accepted methods for management of type II odontoid fractures among the elderly. Consideration was given to both operative and non-operative treatment, as well as factors which determined which method was chosen. Outcomes for each were likewise considered.
Results: Operative treatments consist of trans-odontoid screw fixation, C1-C2 trans-articular fixation/arthrodesis and occipital-cervical fixation/arthrodesis. Non-operative treatments include cervical collar immobilization and halothoracic bracing. Factors determining which method is chosen include patient anatomy, co-morbidities, and the level of comfort and experience of the treating surgeon.
Conclusions: As the general population continues to age, the frequency of these injuries will no doubt increase. With improvements in surgical and anesthesia technique, the viability of operative treatment in even the extremely aged is quite good. However in light of the looming changes in the healthcare system, and the socioeconomic impact of an aging population, the need for more cost-effective means of treating patients is obvious. While the rate of radiographic osseous healing of these fractures which are treated non-operatively is low, it appears that a fibrous union may well be adequate from a functional and quality of life standpoint.
Keywords: Odontoid Fracture, Halothoracic Brace, Fixation, Fibrous Union
Objectives: Identify currently accepted methods for treating type II odontoid fractures in elderly patients. Make informed treatment decisions based on considering factors which determine the most appropriate method. Better understand the socioeconomic impact that an aging population will have on how we allocate neurosurgical resources.
Subject: Socioeconomic
Title: A retrospective study of a novel coding education program in accordance with ACGME practice based learning and systems based practice: a new addition to modern neurosurgery residency training?
Authors: Paul E Kaloostian; Martina Stippler
Introduction: The Accreditation Council for Graduate Medical Education (ACGME) and American Association of Medical Colleges (AAMC) have implemented the 6 core competencies into resident training. Current neurosurgery resident training does not include a standardized coding educational program which results in lack of resident coding skills after residency and significant loss of reimbursement for the institution. Our aim was to blindly analyze one residentís operative dictations before and after instituting a standardized monthly coding course for 12 months within a neurosurgery residency.
Methods: Sixty operative notes were randomly obtained: thirty operative notes before instituting the coding course and thirty notes after completion. Our neurosurgery coder graded the operative notes in a standardized blind fashion. Points were assigned to every coding mistake noted. All operative notes were from one resident. Results were then tallied in a blind fashion by two physicians within neurosurgery.
Results: The average number of mistakes in the operative notes before and after were 31 and 19.5, respectively (Figure 1). There was a statistically significant improvement (p<0.05) in resident coding practices during this time.
Conclusions: The utilization of our neurosurgery faculty and coder in teaching the monthly educational coding courses, along with resident involvement in coding education, has shown to be a successful method of not only improving resident coding practices but also a method of satisfying ACGME required systems based practice and practice based learning strategies in residency education. Including this in the current neurosurgery residency program is recommended.
Keywords: systems based practice, practice based learning, residency, neurosurgery
Objectives: 1.Understand requirments for ACGME guided systems based practice and practice based learning 2. Understand the importance of coding education in neurosurgery residency 3. Understand one method of utilizing coding education team to educate residents
Subject: Trauma
Title: Improved Mortality Rates & Factors Predicting Good Outcomes in Elderly Patients Undergoing Craniotomy for Evacuation of Acute Subdural Hematomas
Authors: Christian A. Bowers; Andrew Dailey
Introduction: Acute subdural hematomas (ASDH) have been reported to carry mortality rates of 80% in patients older than 55 years of age with functional survival rates quoted as low as 9% in patients older than 65 years. We hypothesized that our outcomes were better than what has been reported.
Methods: The authors retrospectively reviewed the cases of all elderly patients (>65 years old) with acute subdural hematoma (ASDH) treated with craniotomy at the University of Utah between 2000-2010. Patients were located using the OpCoder database and their demographic information, including clinical presentation of pre-operative Glascow Coma Score (GCS) and Glasgow Outcome Scale (GOS) at time of discharge were recorded and analyzed.
Results: Thirty-eight patients with an average age of 76.8 years old underwent craniotomy for ASDH. 66.7% of patients without bilaterally fixed pupils upon presentation survived to hospital discharge. Among the survivors, 13 (59.1%) were GOS-4/5, while the other 8 survivors (40.9%) were GOS-3. Univariate comparisons were made with outcome of alive or dead at discharge. Significant associations were observed with GCS=3 (p=.006), and pupils (p=.013). We then developed a predictive model. The variables entered were anticoagulation (Yes/No), pupils, GCS, age, Rotterdam. The only factor that predicted alive or dead at discharge was GCS, specifically GCS of 3. We repeated the analysis with the outcome : goodgos (GOS 4 or 5). In the univariate analysis, pupils (p=.01) and GOS (p=.035) were the only significant associations with goodgos. With the new analysis, the only variable that entered the model was pupils.
Conclusions: A patient with bilaterally reactive pupils had a 1:1 (50%) chance of obtaining goodgos but this increased to 2:1 (66.7%) if the patient had a preoperative GCS of 13-15. If one or both pupils were non-reactive, then there were no patients achieving goodgos.
Keywords: Acute subdural, Elderly, TBI, mortality rates
Objectives: 1) Describe the reported survival rates for evacuation of traumatic acute subdural hematomas in the elderly 2) Know what factors predispose to good outcomes 3) Educate other physicians with respect to prognosis for elderly patients with traumatic acute subdural hematomas based on presenting GCS and the presence or absence of papillary abnormalities.
Subject: Pediatrics
Title: Efficacy of Clip-Wrapping in Treatment of Complex Pediatric Aneurysms
Authors: Christian A. Bowers; William Couldwell
Introduction: Pediatric aneurysms (PAs) are a rare clinical entity distinct from their adult counterparts with respect to their typical location, aneurysm type, patient demographics, known predisposing risk factors, Hunt-Hess grade after rupture, clinical outcome, propensity to hemorrhage, rehemorrhage, and recur. A myriad of strategies have been employed to treat PAs, but although it has been used frequently in adults, the use of clip-wrapping in pediatric patients has only been reported once. We present a small series of pediatric patients that underwent clip-wrapping for treatment of their aneurysms and discuss this strategy as an effective means of treating unclippable pediatric aneurysms.
Methods: We performed a retrospective chart cohort review of pediatric aneurysm patients treated with clip-wrapping by a single surgeon over a 5-year period. Clinical presentation, surgical management, and clinical and radiological outcome of the patients were evaluated.
Results: Five patients were treated with clip-wrapping during the specified period. Three patients had traumatic pseudoaneurysms, with two subarachnoid hemorrhages from aneurysm rupture. One patient presented with mycotic pseudoaneurysm rupture causing a large intraparenchymal and subarachnoid hemorrhage. Another patient had a dissected complex saccular aneurysm with 4 perforating vessels arising from the dome. All patients with available follow-up had good clinical results, with Glasgow outcome scale scores of 5 at 6 months or 1 year. Post-operative neuroimaging demonstrated vessel patency after clip-wrapping with no recurrent hemorrhages or increase in aneurysm size during follow-up.
Conclusions: Clip-wrapping appears to be an effective yet very underutilized technique for treatment of complex pediatric aneurysms that are not amenable to conventional methods. A few previously reported cases demonstrate long-term success of clip-wrapping in pediatric patients with complex aneurysms and our experience doubles the previously reported cases while supporting clip-wrapping as an effective tool.
Keywords: Complex aneurysms; pediatric; clip-wrapping
Objectives: 1- Understand the characteristics of pediatric aneurysms and know how they differ from their adult counterparts. 2- Know the commonly employed strategies in treating complex pediatric aneurysms that are not amenable to standard clipping & the reported success rates of clip-wrapping. 3- Understand the advantages & disadvantages of clip-wrapping as a treatment strategy in complex pediatric aneurysms.
Subject: Socioeconomic
Title: Neurocritical care training for the neurosurgery resident: should it continue?
Authors: Paul E Kaloostian; Howard Yonas
Introduction: The majority of current neurosurgery training programs do not emphasize neurocritical care (NCC) for many reasons, such as the intensely busy neurosurgical service requirements and the presence of NCC intensivists. The Leapfrog group, established in 2000 in response to a variety of preventable medical errors, has begun to lead patient care in the neurosurgical intensive care units around the country. Our aim was to determine what current neurosurgery residents in different levels of residency and program directors
Methods: Surveys were sent out electronically to all residency programs. 39 responses from junior residents, 36 responses from senior/chief residents, and 8 responses from program directors/chairman were obtained.
Results: Results shown in Figure 1 and 2. No statistical difference between the majority responses of the different level residents, and between program directors/chairman and combined resident responses.
Conclusions: Clearly, neurosurgery residents of all levels and program directors/chairman value NCC education and see a valuable role for this knowledge in their future. Most residents however do not want to spend an additional year of fellowship training to become certified neurointensivists. The majority of residents and program directors/chairman surveyed agree not to spend a year solely dedicated to NCC. A variety of procedures such as intracranial monitoring devices, arterial lines, intubations, and central lines are clearly valued by neurosurgery residents as procedures they want to do. Perhaps a shift in current standard neurosurgery resident training to include a focused 3-6 month rotation on the ICU service working as a team with the hospitalists may be an optimal educational experience.
Keywords: neurocritical care, resident, neurosurgery, neurointensivists
Objectives: Determine junior and senior resident perceptions of Neurocritical care training during residency training Determine program director/chairman perceptions of Neurocritical care education during current residency training Determine what role neurocritical care education has in current and future neurosurgical residency programs
Subject: Spine
Title: Prospective Study of Human Juvenile Chondrocytes for Treatment of Discogenic Back Pain Secondary to Lumbar Degenerative Disc Disease
Authors: Domagoj Coric; Kenneth Pettine; Andrew Sumich; Margaret O. Boltes; Huston D. Adkisson
Introduction: Mechanical lower back pain (LBP) is difficult to diagnose and treat, and the vast majority of patients with LBP respond to nonsurgical management. The purpose of this ongoing, phase I, prospective, single-arm study was to evaluate the safety and initial efficacy of a cellular therapy for patients with lumbar mechanical LBP due to degenerative disc disease (DDD).
Methods: Fifteen patients with clinically diagnosed LBP recalcitrant to at least 6 months of nonsurgical management were enrolled. MRI confirmed single-level DDD at L3-S1 and discography confirmed annular integrity. Each patient received a single percutaneous treatment of human juvenile chondrocytes blended with fibrin carrier. Baseline Oswestry Disability Index (ODI), Numerical Rating Scale (NRS) for pain, SF-36 and neurological exams were compared at Months 1, 3, 6 and 12 post-op. Adverse events were monitored continually to evaluate safety of the cellular therapy and percutaneous delivery procedure.
Results: Mean patient age was 40 years (range 19-47). Treatment levels were L3/4=2, L4/5=1, L5-S1/12; Pfirrmann grade III=12; grade IV=3. Mean injection volume and mean peak injection pressure was 1.3mL (10 million cells per mL) and 87.6 psi, respectively. Injection time ranged from 5-33 seconds. Fourteen of 15 patients (93%) have completed minimum 1yr follow-up. Mean ODI (baseline=53.33; 12 months=20.21; p=<0.0001), NRS (baseline=5.73; 12 months=3.07; p=0.0019) and SF-36 (Physical Component) scores (baseline=35.45; 12 months=46.84; p=0.0003) improved significantly from baseline. There were no disc infections, neurological events felt to represent clinical deterioration, immunological response to treatment or serious unexpected adverse events. Three patients (20%) underwent TDR by 12 month due to persistent LBP.
Conclusions: This is a report of the safety and preliminary clinical efficacy of juvenile chondrocytes for the treatment of lumbar DDD with mechanical LBP. Clinical results at 12 months are encouraging with statistically significant improvements in both pain and function (ODI, NRS and SF-36). A prospective, randomized, double-blinded, placebo-controlled study is under design with enrollment targeted for Q42012.
Keywords: Discogenic back pain, nucleus repair, chondrocytes, degenerative disc disease
Objectives: 1. Recognize that cellular therapies other than stem cells are under investigation for disc nucleus repair. 2. Discuss the molecular basis of chondrocyte immune privilege that permits allogeneic transplantation without immunologic rejection. 3. Identify the transcription factor regulating chondrocyte survival in an avascular environment, such as the disc space.
Subject: Tumor
Title: Intracranial Metastatic Choriocarcinoma
Authors: Charles V Hatchette
Introduction: We report the case of a woman who presented with headache and lethargy and was found to have hydrocephalus and a large right cerebellar enhancing lesion with associated mass effect. She was treated with a ventriculostomy and steroids. Upon workup her beta-HCG was elevated and choriocarcinoma was suspected, and empiric chemotherapy was started. She was subsequently taken for surgical resection of the lesion due to its extensive mass effect. She tolerated this procedure well, and the ventriculostomy was removed without the need for shunt placement. The successful treatment of this patient involved the multidisciplinary effort of neurosurgery, hematology oncology, and obstetrics and gynecology.
Methods: This is a retrospective chart review
Results: After being treated with a combination of chemotherapy and surgical resection, the patient made a good functional recovery
Conclusions: Choriocarcinoma intracranial metastasis is a rare and potentially challenging problem that requires surgical resection in some cases, and is best treated with a multidisciplinary approach.
Keywords: Choriocarcinoma, Metastasis
Objectives: Describe the pathologic features of choriocarcinoma, state the operative indications for choriocarcinoma intracranial metastasis, explain the multidisciplinary approach necessary to best treat these lesions
Subject: Spine
Title: Surgical Treatment of Spinal Tumors
Authors: Yevgeniy Khavkin
Introduction: Neurosurgeons should be familiar with the principles of surgical treatment of spinal tumors. Even though not all neurosurgeons perform complex spine procedures, knowing the literature and available surgical and non surgical approaches to the treatment of spinal tumor, helps provide better care for our patients.
Methods: Review of literature and case reports
Results: Surgical treatment can be effective in improving quality of life in patients with metastatic spine lesions and extend survival in the patients with primary spine tumors.
Conclusions: Surgery should be considered for the treatment metastatic and primary spine tumors.
Keywords: Spine, Tumors, Surgery, Sacrectomy
Objectives: 1. Recognize the difference in surgical approaches to the metastatic and primary spine tumors 2. Learn about different techniques for the surgical treatment of spine tumors 3. Familiarize yourself with available literature and evidence based approach to the surgery for spine tumors.
Subject: Socioeconomic
Title: The Future of Neurosurgery from the Hospital Perspective: Where are We Headed?
Authors: Kelly Schmidt
Introduction: From a hospital perspective, neurosurgical volume is continuously changing. Particularly with development of new and improved technology, a focus on more minimally invasive procedures, and a steady foray into fields that now have a procedural component performed by some neurosurgeons (neurology, radiology, and oncology). Given steadily declining reimbursement, it is in a hospitalís best interest to try to predict the future trends of neurosurgical procedures so as to prepare for major changes that could affect their bottom line. These trends should also be of interest to individual neurosurgeons.
Methods: Data from an independent research group employed by a hospital corporation was reviewed. The research group predicts trends by taking a disease-based look at current utilization of diagnostics and surgical care and integrating that data with the expected driving economic forces, epidemiology, and emerging clinical innovations and technology. The data produced includes a population based forecast as well as the research groupís predicted forecast of the national trends for cranial and spinal surgery over the next ten years.
Results: Areas within neurosurgery that will see the greatest technological advances in the next ten years are predicted to have the largest growth in terms of procedure volume. Specifically this includes tumor surgery and radiosurgery, endovascular procedures, and deep brain stimulation. Spine surgery, as an area of neurosurgery that is being closely scrutinized by insurance companies, is predicted to have the smallest growth in terms of procedure volume as well as a distinct shift towards outpatient care.
Conclusions: As neurosurgeons, the predicted trends for neurosurgical procedure volume over the next ten years could have potential impact on patient care, our individual practices, and our relationship with hospitals.
Keywords: Neurosurgery Economics, Utilization, Future Trends
Objectives: Discuss the predicted trends of cranial and spine surgery over the next ten years.
Subject: Functional
Title: Clinical Experience with Ferromagnetic Dissection Tool
Authors: Joel D. MacDonald
Introduction: The ability to cut and coagulate during soft tissue dissection are essential to virtually all surgical procedures. There are a variety of energy based technologies available for this purpose. We have evaluated a novel device that uses ferromagnetic (FM) heat induction to incise and coagulate simultaneously without passing current through the patient.
Methods: Surgical cases at 2 institutions since the introduction of the FM device a year ago.THe device has been used in procedures ranging from spine to functional neurosurgery. Procedural details were examined for the utility of the FM device.
Results: A series of cranial and spinal procedures were identified. Case examples will be demonstrated.
Conclusions: The FM device has demonstrated utility in a range of clinical applications.
Keywords: Ferromagnetic, Dissection,
Objectives: Participants will be able to discuss the physical principles behind the ferromagnetic heat induction device. Participants will be able to discuss potential applications of the FM device to various surgical procedures. Participants will be able to discuss similarities and differences between FM and other technologies.
Subject: Tumor
Title: Primary Treatment of Low Grade Glioma with Multi-agent Chemotherpy
Authors: edward b arenson
Introduction: Between 1995 and 2012 we treated 64 patients with low grade gliomas (LGG). Median follow-up is 79 months, mean 75 months, and range 14-196. There were 17 astrocytomas, 32 oligodendrogliomas (ODG), and 15 mixed tumors. Of 37 patients whose tumors were tested for 1p19q co-deletion, 23 were positive. 52 patients were treated with primary chemotherapy, and 12 received no post-surgical treatment. We report the results of this large group of patients with LGG treated by a single investigator with primary chemotherapy.
Methods: Based on the fact that cancer is seldom, if ever, curable with single agent chemotherapy, we chose to create a hybrid regimen (mPCV) which combines temozolomide (TMZ) the current standard, with PCV (minus procarbazine) the excessively toxic regimen first shown to be effective in LGG.
Results: 52 patients were treated with primary chemotherapy. This regimen was well tolerated; there were no treatment related deaths and 1 patient was hospitalized with shingles. The mean number of monthly courses of mPCV was 12, (range 1-20). Of 632 monthly courses, there were 73 episodes (12%) OF grades III/IV leukopenia and 40 episodes (6%) of grades III/IV thrombocytopenia. Of 52 patients treated, 16 have relapsed. One progressed at 31 months with GBM and died. The next earliest death occurred at 49 months and the latest at 132. All whose tumors recurred as GBM (9) died. The other 7 have responded to salvage therapy including radiotherapy (RT). Overall survival is 84% and relapse-free survival is 70%. Analysis of survival as a function of tumor type indicates that only 1 of 9 deaths occurred among 23 patients who tested positive for 1p19q co-deletion. Objective response to treatment does not appear to predict outcome.
Conclusions: Follow-up is too brief to predict median survival. Nevertheless, we can conclude that primary chemotherapy appears to be rational and produces results which compare favorably with primary radiotherapy (RT). Further, this approach preserves RT for relapses and, by avoiding RT, offers a better quality of life for survivors.
Keywords: glioma, chemotherapy, oligdendroglioma, survival
Objectives: 1. understand current treatment choices for low grade glioma 2. understand effect of genotype on outcome 3. understand rationale for primary chemotherapy
Subject: Pediatrics
Title: The Use of Noninvasive Electromagnetic Neuronavigation for Intracranial Catheter Placement
Authors: Kelly Schmidt
Introduction: Optimal intracranial catheter placement for shunt or reservoir procedures can be immensely difficult in patients with complicated ventricular anatomy. CT and MRI-guided neuronavigation systems have improved our ability to place catheters in patients with complicated ventricular anatomy. However, standard optical systems have limitations with these procedures. Electromagnetic neuronavigation on the other hand, requires no rigid head fixation, allows the head to be moved freely in space during the procedure, and accurately tracks the tip of the catheter to allow optimal placement within the ventricle.
Methods: A retrospective chart review for a 25 month period identified patients who underwent intracranial catheter placement for any type of shunt or reservoir procedure. 88 patients were identified who underwent a total of 103 procedures. In addition to determining which patients required subsequent catheter revision, the preoperative imaging was evaluated and each procedure was divided into ìroutineî or ìdifficultî catheter placement. The ìdifficultî placement category included slit ventricles, dysmorphic ventricles, and loculated hydrocephalus. The ìroutineî placement category included normal to large-size ventricles or cysts without septations or loculations.
Results: 103 procedures for intracranial catheter placement were performed. 67 (65%) were placed without any type of neuronavigation. The remaining 36 (35%) were placed with neuronavigation ñ 29 (81%) with noninvasive electromagnetic neuronavigation using the Medtronic Stealth Axiem system, the remaining 7 (19%)with standard optical neuronavigation using Medtronic Stealth or BrainLab. During the study period, there was no difference in the rate of proximal catheter revision between the two groups ñ 2 patients (.03%) in the non-navigated group and 1 patient (.03%)in the navigated group required a catheter revision. However, 69% of the navigated procedures were considered to be ìdifficultî placements compared to only .07% of the non-navigated patients.
Conclusions: Noninvasive electromagnetic neuronavigation provides benefits over standard optical neuronavigation and freehand technique for intracranial catheter placement in complicated ventricular anatomy. Use of the Medtronic Stealth Axiem system adds minimal time and cost to the surgical procedure and does not increase the risk to the patient. Optimal catheter placement can prevent postoperative catheter-related complications. Noninvasive electromagnetic neuronavigation should be considered for use in any patient, regardless of their ventricular anatomy.
Keywords: Electromagnetic, Neuronavigation, Ventricular catheter, Shunt, Reservoir
Objectives: Discuss the difference between electromagnetic neuronavigation and optical neuronavigation. Describe the benefits of electromagnetic neuronavigation in pediatric patients and in difficult intracranial catheter placements.
Subject: Tumor
Title: Superior Survival in Glioblastoma with Multi-agent Chemotherapy
Authors: edward b arenson
Introduction: The use of multi-agent chemotherapy to treat glioblastoma (GBM) is based on the fact that single agent therapy seldom, if ever, cures cancer. We report a retrospective review of 74 patients treated by investigator choice between July, 2003 and January 2010 using a modified multi-drug chemotherapy regimen.
Methods: In a previous report (J.Neuro.Oncol.,May 2005,) we presented encouraging results of 37 patients with newly diagnosed GBM treated with BCNU, irinotecan and temozolomide (BITE). Subsequently, we modified BITE to reduce toxicity (mBITE). Patients received daily temozolomide (TMZ) and weekly CPT-11 during radiotherapy (RT) and monthly cycles of TMZ, CPT-11 and paclitaxel alternating with TMZ and BCNU after RT. Patients were treated consecutively save 8 who either elected standard TMZ alone or no post-surgical treatment.
Results: Patients were treated for variable periods of time depending on response and tolerance. All patients experienced at least one episode of grade III/IV hematologic toxicity and 24 patients had grade III/IV G.I. toxicity. There were 16 serious infections and 1 death unrelated to GBM (pneumonia). With a median follow-up of 39 months, median survival was 19 months. By Kaplan-Meier analysis, survival is predicted to be 83% 1 year, 48% 2 year, 37% 3 year, 28% 4 year, and 19% 5 year. A subgroup (24%) of good risk patients defined by high grade resection, age <60 and KPS >70 had median survival of 36 months and 55% predicted 5 year survival. By Chi square analysis, these results are superior to those reported for TMZ alone by Stupp et al, (The Lancet Oncology, May 2009). There is a conspicuous shift in the survival curve at 20 months which seems to predict superior outcome for those patients (approximately 50%) who reach this point without relapse.
Conclusions: We conclude that multi-agent chemotherapy is tolerable and superior in efficacy to single agent TMZ in a single institution. It appears that about half the patients derive the most benefit and may be identifiable at diagnosis using gene expression analysis, (L. Liau, personal communication).
Keywords: glioblastoma, multi-agent chemotherapy, survival, prognosis
Objectives: !. understand guidelines for optimum chemotherapy in cancer 2. understand how these guidelines were developed 3. determine how patients with GBM are most effectively treated with advancing technology
Subject: Spine
Title: The Use of Diagnostic Spinal Injections in Neurosurgery – Indications, Limitations and Potential Complications
Authors:
Introduction: Diagnostic spinal injections can be a very powerful diagnostic tool in the Neurosurgeon’s attempt to identify spinal pain generators and assist in the surgical decision making process. However there are limitations to what information can be discerned from an injection and many carry significant risks and potential for complications.
Methods: Brief overview of the literature.
Results:
Conclusions:
Keywords: Spine, Pain, Injections, Diagnostic ,
Objectives: Demonstrate basic understanding of the 1) selection process in choosing the appropriate diagnostic spinal injection, 2) the limitations of the injection and 3) the potential complications that the patient is exposed to with the injection.