Rate Of Gross Total Resection Research Articles

Subpial en bloc resection improves extent of resection in infiltrating gliomas – A propensity matched comparative cohort analysis

BackgroundSurgery remains the mainstay of glioma therapy and extent of resection is an important prognostic factor. Optimization of surgical outcomes is essential and to this end the technique of resection can potentially play an important role. Based on patterns of glioma growth and extrapolating from other solid cancer surgical principles, a subpial dissection combined with an en-bloc resection (SPER) technique appears to have advantages MethodsWe performed a propensity matched analysis comparing gliomas that were resected using SPER versus a standard piecemeal debulking technique at our centre. Potentially confounding factors (including eloquent location, use of intraoperative imaging, surgeon experience) were adjusted for in the matching of the two cohorts. Outcomes included postoperative morbidity and blinded radiological review documented postoperative ischemia (on diffusion weighted MR imaging - DWI) as well as extent of resection. ResultsIn 57 gliomas (23 SPER and 34 standard), the gross total resection (GTR) rates were significantly higher with SPER (91 vs 65%). Postoperative DWI revealed significant ischemia in almost 50% of cases in either group, though many did not have postoperative deficits. Arterial ischemia was higher in the standard surgery group and this was associated with a significantly higher risk (seven times) of resulting in prolonged neurological deficits. ConclusionsSPER is a useful technique which increases the GTR rates in gliomas undergoing resection. It is associated with lower incidence of arterial ischemia in the postoperative period and this can result in improved long term functional outcomes.

Surgical Outcomes of Sphenoid Wing Meningioma with Periorbital Invasion.

ObjectiveThe aim of this study was to evaluate the clinical outcome of sphenoid wing meningioma with periorbital invasion (PI) after operation. MethodsSixty one patients with sphenoid wing meningioma were enrolled in this study. Their clinical conditions were monitored after the operation and followed up more than 5 years at the outpatient clinic of a single institution. Clinical and radiologic information of the patients were all recorded including the following parameters : presence of PI, presence of peri-tumor structure invasion, pathologic grade, extents of resection, presence of hyperostosis, exophthalmos index (EI), and surgical complications. We compared the above clinical parameters of the patients with sphenoid wing meningioma in the presence or absence of PI (non-PI), then linked the analyzed data with the clinical outcome of the patients. ResultsOf 61 cases, there were 14 PI and 47 non-PI patients. PI group showed a significantly higher score of EI (1.37±0.24 vs. 1.00±0.01, p<0.001), more frequent presence of hyperostosis (85.7% vs. 14.3%, p<0.001), and lower rate of gross total resection (GTR) (35.7% vs. 68.1%, p=0.032). The lower score of pre-operative EI, the absence of both PI and hyperostosis, smaller tumor size, and the performance of GTR were associated with lower recurrence rates in the univariate analysis. However, in the multivariate analysis, the performance of GTR was the only significant factor to determine the recurrence rate (p=0.043). The incidences of surgical complications were not statistically different between the subtotal resection (STR) and GTR groups, but it was strongly associated tumor size (p=0.017). ConclusionThe GTR group showed lower recurrence rate than the STR group without differences in the surgical complications. Therefore, the GTR is strongly recommended to treat sphenoid wing meningioma with PI for the better clinical outcome.

500 Fluorescein-guided Resection of High Grade Gliomas: A Meta-analysis

INTRODUCTION: High grade gliomas (HGGs) have a poor prognosis despite current standard of care of surgery, chemotherapy, and radiation therapy. Achieving gross total resection (GTR) has been found to prolong survival in these patients. Intraoperative fluorescent agents are often used to aid resection of HGGs. Currently, 5-ALA is the only FDA-approved fluorescent agent but can be inconvenient to use, requiring ingestion hours before surgery, dark room isolation for 1-2 days post-operatively, and high cost. Another fluorescent agent commonly used is fluorescein sodium which is FDA approved for ocular surgeries and has a better side effect profile and is less costly than 5-ALA. Many studies have been published documenting the use of fluorescein in HGG resection, reporting rates of GTR and with some studies comparing it to a non-fluorescent or 5-ALA arm. In this meta-analysis, we provide statistical evidence of the efficacy in using fluorescein for HGG resection. METHODS: Following the PRISMA framework, we assessed 119 articles from Pubmed, Medline (Ovid), and BIOSIS Citation Index and found 23 eligible studies for meta-analysis, assessing the rates of GTR with fluorescein-guided resection of HGGs. RESULTS: Of the 23 eligible studies, 22 reported GTR rates. A pooled cohort of 336 patients underwent fluorescein-guided HGG resection with a GTR rate of 81% (95% CI, 73-89%; p&lt;.001). 11 case-controlled studies were analyzed, showing a 23.6% increase in GTR rate in the fluorescein group compared to non-fluorescein-guided surgeries. CONCLUSION: This meta-analysis shows significantly increased GTR rates in fluorescein-guided resection of HGGs when compared to resection without fluorescein. This is comparable to GTR rates found with 5-ALA (76.8%) in previous meta-analyses. Though our results are statistically significant, there was significant heterogeneity in the fluorescein studies analyzed, so we cannot definitively conclude an association between fluorescein-guidance and GTR.

Minimally Invasive Tubular Retractor Surgery for Intradural Extramedullary Spinal Tumor Reduces Postoperative Degeneration of Paraspinal Muscle.

Background Minimally invasive surgery (MIS) using a tubular retractor has been increasingly utilized in spinal surgery for degenerative conditions with the benefit of paraspinal muscle preservation. This benefit has not been previously reported for intradural extramedullary tumors using the MIS approach. In this study, we aimed to compare the degree of postoperative fatty degeneration in paraspinal muscle between MIS with tubular retractor (MIS) and open laminectomy (Open) for intradural extramedullary spinal tumors. Methods This was a retrospective review conducted in a tertiary neurosurgical center from 2015 to 2019. The degree of paraspinal muscle fatty degeneration, as measured by Goutallier grade on postoperative magnetic resonance imaging (MRI), was analyzed, and the degree of excision, tumor recurrence rate, and chronic pain were compared between the two surgical approaches. Results Among 9 patients in the MIS group and 33 patients in the Open group, the rate of gross total resection was comparable (MIS: 100.0%, Open: 97.0%, p = 1.000). The degree of paraspinal muscle fatty degeneration was significantly reduced in the MIS group (median Goutallier grade 1 in MIS group vs. median Goutallier grade 2 in Open group, p = 0.023). There was no significant difference in the tumor recurrence rate, complication rate, and chronic pain severity. A consistent trend of reduced analgesic consumption was observed in the MIS group, though not statistically significant. Conclusions Minimally invasive tubular retractor surgery is an effective approach for appropriately selected intradural extramedullary spinal tumors with significantly reduced postoperative fatty degeneration in paraspinal muscle.

Cauda equina ependymomas: surgical treatment and long-term outcomes in a series of 125 patients.

Cauda equina ependymoma (CEE) is a rare tumor for which little information is available on the oncological and clinical outcomes of patients. In this study the authors aimed to address functional, oncological, and quality-of-life (QOL) outcomes in a large series of consecutive patients operated on at their institution during the past 20 years. The records of 125 patients who underwent surgery between January 1998 and September 2018 were reviewed. Analyzed variables included demographic, clinical, radiological, surgical, and histopathological features. Neurological outcomes were graded according to the McCormick and Kesselring scales. The QOL at follow-up was evaluated by administering the EQ-5DL questionnaire. On admission, 84% of patients had a McCormick grade of I and 76.8% had a Kesselring score of 0. At follow-up (clinical 8.13 years; radiological 5.87 years) most scores were unchanged. Sacral level involvement (p = 0.029) and tumor size (p = 0.002) were predictors of poor functional outcome at discharge. Tumor size (p = 0.019) and repeated surgery (p < 0.001) were predictors of poor outcome. A preoperative McCormick grade ≥ III and Kesselring grade ≥ 2 were associated with worse outcomes (p = 0.035 and p = 0.002, respectively). Myxopapillary ependymoma (MPE) was more frequent than grade II ependymoma (EII). The overall rate of gross-total resection (GTR) was 91.2% and rates were significantly higher for patients with EII (98%) than for those with MPE (84%) (p = 0.0074). On multivariate analysis, the only factor associated with GTR was the presence of a capsule (p = 0.011). Seventeen patients (13.7%) had recurrences (13 MPE, 4 EII; 76.4% vs 23.6%; p = 0.032). The extent of resection was the only factor associated with recurrence (p = 0.0023) and number of surgeries (p = 0.006). Differences in progression-free survival (PFS) were seen depending on the extent of resection at first operation (p < 0.001), subarachnoid seeding (p = 0.041), piecemeal resection (p = 0.004), and number of spine levels involved (3 [p = 0.016], 4 [p = 0.011], or ≥ 5 [p = 0.013]). At follow-up a higher proportion of EII than MPE patients were disease free (94.7% vs 77.7%; p = 0.007). The QOL results were inferior in almost all areas compared to a control group of subjects from the Italian general population. A McCormick grade ≥ 3 and repeated surgeries were associated with a worse QOL (p = 0.006 and p = 0.017). An early diagnosis of CEE is important because larger tumors are associated with recurrences and worse functional neurological outcomes. Surgery should be performed with the aim of achieving an en bloc GTR. The histological subtype was not directly associated with recurrences, but some of the features more commonly encountered in MPEs were. The outcomes are in most cases favorable, but the mean QOL perception is inferior to that of the general population.

Treatment strategies for giant pituitary adenomas in the era of endoscopic transsphenoidal surgery: a multicenter series.

Given the anatomical complexity and frequently invasive growth of giant pituitary adenomas (GPAs), individually tailored approaches are required. The aim of this study was to assess the treatment strategies and outcomes in a large multicenter series of GPAs in the era of endoscopic transsphenoidal surgery (ETS). This was a retrospective case-control series of 64 patients with GPAs treated at two tertiary care centers by surgeons with experience in ETS. GPAs were defined by a maximum diameter of ≥ 4 cm and a volume of ≥ 10 cm3 on preoperative isovoxel contrast-enhanced MRI. The primary operation was ETS in all cases. Overall gross-total resection rates were 64% in round GPAs, 46% in dumbbell-shaped GPAs, and 8% in multilobular GPAs (p < 0.001). Postoperative outcomes were further stratified into two groups based on extent of resection: group A (gross-total resection or partial resection with intracavernous remnant; 21/64, 33%) and group B (partial resection with intracranial remnant; 43/64, 67%). Growth patterns of GPAs were mostly round (11/14, 79%) in group A and multilobular (33/37, 89%) in group B. In group A, no patients required a second operation, and 2/21 (9%) were treated with adjuvant radiosurgery. In group B, early transcranial reoperation was required in 6/43 (14%) cases due to hemorrhagic transformation of remnants. For the remaining group B patients with remnants, 5/43 (12%) underwent transcranial surgery and 12/43 (28%) underwent delayed second ETS. There were no deaths in this series. Severe complications included stroke (6%), meningitis (6%), hydrocephalus requiring shunting (6%), and loss or distinct worsening of vision (3%). At follow-up (mean 3 years, range 0.5-16 years), stable disease was achieved in 91% of cases. ETS as a primary treatment modality to relieve mass effect in GPAs and extent of resection are dependent on GPA morphology. The pattern of residual pituitary adenoma guides further treatment strategies, including early transcranial reoperation, delayed endoscopic transsphenoidal/transcranial reoperation, and adjuvant radiosurgery.

A propensity-adjusted comparison of endoscopic endonasal surgery versus transcranial microsurgery for pediatric craniopharyngioma: a single-center study.

When comparing endoscopic endonasal surgery (EES) and transcranial microsurgery (TCM) for adult and mixed-age population craniopharyngiomas, EES has become an alternative to TCM. To date, studies comparing EES and TCM for pediatric craniopharyngiomas are sparse. In this study, the authors aimed to compare postoperative complications and surgical outcomes between EES and TCM for pediatric craniopharyngiomas. The data of pediatric patients with craniopharyngiomas who underwent surgery between February 2009 and June 2021 at a single center were retrospectively reviewed. All included cases were divided into EES and TCM groups according to the treatment modality received. The baseline characteristics of patients were compared between the groups, as well as surgical results, perioperative complications, and long-term outcomes. To control for confounding factors, propensity-adjusted analysis was performed. Overall, 51 pediatric craniopharyngioma surgeries were identified in 49 patients, among which 35 were treated with EES and 16 were treated with TCM. The proportion of gross-total resection (GTR) was similar between the groups (94.3% for EES vs 75% for TCM, p = 0.130). TCM was associated with a lower rate of hypogonadism (33.3% vs 64.7%, p = 0.042) and a higher rate of growth hormone deficiency (73.3% vs 26.5%, p = 0.002), permanent diabetes insipidus (DI) (60.0% vs 29.4%, p = 0.043), and panhypopituitarism (80.0% vs 47.1%, p = 0.032) at the last follow-up. CSF leakage only occurred in the EES group, with no significant difference observed between the groups (p > 0.99). TCM significantly increased the risk of worsened visual outcomes (25.0% vs 0.0%, p = 0.012). However, TCM was associated with a significantly longer median duration of follow-up (66.0 vs 40.5 months, p = 0.007) and a significantly lower rate of preoperative hypogonadism (18.8% vs 60.0%, p = 0.006). The propensity-adjusted analysis revealed no difference in the rate of recurrence, hypogonadism, or permanent DI. Additionally, EES was associated with a lower median gain in BMI (1.5 kg/m2 vs 7.5 kg/m2, p = 0.046) and better hypothalamic function (58.3% vs 8.3%, p = 0.027) at the last follow-up. Compared with TCM, EES was associated with a superior visual outcome, better endocrinological and hypothalamic function, and less BMI gain, but comparable rates of GTR, recurrence, and perioperative complications. These findings have indicated that EES is a safe and effective surgical modality and can be a viable alternative to TCM for pediatric midline craniopharyngiomas.

822 Awake Craniotomy Within Glioblastoma Subgroups (GLIOMAP study)

INTRODUCTION: Awake mapping has been associated with decreased neurological deficits and increased extent of resection in eloquent glioma resections. However, its impact within clinically relevant glioblastoma subgroups remains poorly understood. METHODS: 918 patients with tumor resection for primary eloquent glioblastoma between 2010 and 2020 at four tertiary centers from Europe and the United States were included from an initial cohort of 4075 patients. Awake patients were matched with asleep patients for the overall cohort and subgroups. RESULTS: Overall, awake mapping led to less neurological deficits at 6 weeks (18.4% vs. 27.8%, p = 0.036) and 6 months postoperatively (26.5% vs. 41.9%, p = 0.0039), lower residual volume (mean: 1.9 vs. 6.4 ml, p = 0.0076), a higher extent of resection (mean: 95.5% vs. 85.3%; median: 99.8% vs. 94.0%, p &lt; 0.001), and longer overall survival (median: 20.0 vs. 18.5 months, p = 0.042). Awake mapping led in the subgroups of age &lt; 70, age = 70, preoperative NIHSS score 0-1 and preoperative KPS 90-100 to less postoperative neurological deficits at 6 weeks and 6 months. For patients in the KPS = 80 subgroup, awake mapping led to less postoperative neurological deficits at 6 months (22.0% vs. 45.9%, p = 0.026). Patients aged &lt; 70 years undergoing awake craniotomy had on average a longer overall survival than the asleep resection group (median: 24 months vs. 20.5 months, p= 0.031). Awake mapping was an independent predictor for receiving adjuvant chemotherapy and radiotherapy (OR for no receival: 0.40, p = 0.025), gross-total resection based on residual volume (OR 2.79, p = 0.041), and gross-total resection based on extent of resection (OR 2.24, p = 0.002). Moreover, it had a positive impact on overall survival in the = 70 subgroup (HR 0.08, p = 0.033), but a negative impact on overall survival in the NIHSS = 2 subgroup (HR 3.07, p = 0.014). CONCLUSIONS: Awake mapping prevents postoperative neurological deterioration in eloquent glioblastoma resections for patients aged &lt;70, aged = 70, with a preoperative NIHSS score of 0-1 or preoperative KPS of 90-100 and increases the rate of gross-total resections in all patients.

Anterior Skull Base Meningioma: Surgical Approach and Complication Avoidance.

Introduction Endoscopic endonasal approach (EEA) and keyhole transcranial approaches (TCAs) are being increasingly used in anterior skull base meningioma (ASBM) surgery. Objective We compare tumor resection rates and complication profiles of EEA and supraorbital keyhole approach (SOKHA) with conventional TCAs. Methods Fifty-four patients with ASBM (olfactory groove meningioma [OGM], n = 19 and planum sphenoidale/tuberculum sellae meningioma [PSM/TSM], n = 35) operated at a single center over 7 years were retrospectively analyzed. Results The overall rate of gross total resection (GTR) was higher in OGM (15/19, 78.9%) than PSM-TSM group (23/35, 65.7%, p = 0.37). GTR rate with OGM was 90% and 75% with TCA and EEA. Death ( n = 1) following medical complication (TCA) and cerebrospinal fluid leak requiring re-exploration ( n = 2, one each in TCA and EEA) accounted for the major complications in OGM. For the PSM/TSM group, the GTR rates were 73.3% ( n = 11/15), 53.8% ( n = 7/13), and 71.4% ( n = 5/7) with TCA, EEA, and SOKHA, respectively. Seven patients (20%) of PSM-TSM developed major postoperative complications including four deaths (one each in TCA and SOKHA, and two in EEA groups) and three visual deteriorations. Direct and indirect vascular complications were common in lesser invasive approaches to PSM-TSM especially if the tumor has encased intracranial arteries. Conclusion No single approach is applicable to all ASBMs. TCA is still the best approach to obtain GTR but has tissue trauma-related problems. SOKHA may be a good alternative to TCA in selected PSM-TSMs, while EEA may be an alternate option in some OGMs. A meticulous patient selection is needed to derive reported results of EEA for PSM-TSM.

Embolization of a third ventricular choroid plexus papilloma: illustrative case.

BACKGROUNDChoroid plexus tumors are rare neoplasms that are typically found in the lateral ventricles. They have infrequently been reported in the third ventricle, and treatment strategies have varied.OBSERVATIONSThe authors described a 6-month-old patient who presented with irritability and hypotonia. The patient was found to have a large tumor in the third ventricle with obstructive hydrocephalus. Preoperative angiography revealed a feeding artery from the right medial posterior choroidal artery (MPChA). The feeding artery was effectively embolized, and the patient subsequently received open resection of the tumor. Pathology revealed features consistent with atypical choroid plexus papilloma (CPP).LESSONSChoroid plexus tumors are often hypervascular, which can often make gross total resection (GTR) difficult. Preoperative angiography of tumors identifies feeding vessels, and embolization has the potential to decrease perioperative blood loss and allow for a higher GTR rate. Third ventricular CPPs appear to invariably receive vascular supply from the MPChA, arising from the right posterior cerebral artery. Embolization followed by resection of a choroid plexus tumor in the third ventricle is an effective treatment strategy.

Pediatric pituitary adenomas are more aggressive, more likely to be hormone producing and are more difficult to cure than adult pituitary adenomas: case series and systematic literature review.

Pediatric pituitary adenomas (pPAs) are uncommon. Thus, their presentation and outcomes after treatment are less well-understood than those of pituitary adenomas in adulthood (aPAs). A retrospective chart review was conducted for all patients who underwent endoscopic endonasal transsphenoidal surgery (EETS) for pPA at NewYork-Presbyterian Hospital/Weill Cornell Medicine (NYP/WCM) from 2005-2020. Eleven patients were identified, and information pertaining to age, sex, adenoma characteristics, procedural details, and outcomes was reviewed. A systematic review of the literature was also performed to compare outcomes of EETS versus microscopic endonasal transsphenoidal surgery (METS) for pPA. From 2005-2020, 11 patients underwent EETS for pPA at NYP/WCM. Mean age at operation was 14.9 ± 2.7years, and 5 patients (45.5%) were male. 10 adenomas (90.9%) were hormone-producing. Of the functional adenomas, 8 (80.0%) were PRL-secreting and 2 (20.0%) were GH-secreting. Maximum adenoma diameter (MAD) ranged from 1.2-5.1cm, with a median of 1.55cm. Cavernous sinus invasion (CSI) occurred in 2 patients with macroprolactinoma. Gross total resection (GTR) was achieved in 10 (90.9%). Biochemical remission occurred in 5/10 (50.0%). Post-operative complications were documented in 8 cases (72.7%) and included diabetes insipidus, hypopituitarism, sinusitis, weight gain, cerebrospinal fluid leak, meningitis, and hydrocephalus. Systematic literature review of 105 microscopic and 175 endoscopic cases revealed high frequency of hormone-producing tumors (83.6%) and similar rates of GTR (82.4% vs 85.1%) and biochemical cure (75.8% vs 64.3%). pPAs are more likely to be hormone producing and may be more aggressive and difficult to cure than aPAs. EETS is an effective treatment, although complication rates may be higher than in adult populations.

Posterior fossa epidermoid tumors: a single-center study and proposed classification system

Background Epidermoid tumors of the cerebellopontine angle and posterior fossa account for approximately 1% of all intracranial tumors. Classifications that may guide surgical planning in the current neurosurgical practice are lacking. This study aimed to focus on the surgical outcome and suggest a classification system that may aid neurosurgeons in determining the goal of resection to minimize morbidity and mortality rates. Methods The study population comprised patients who underwent surgery and follow-up for tissue-proven epidermoid tumors between 2015 and 2020. Patients’ data, including demographic features, clinical symptomatology, the extent of surgical resection, and postoperative outcomes, were retrospectively evaluated. A new classification system was designed based on the anatomical–radiological findings and was evaluated in terms of clinical symptomatology, radiological features, surgical approach, and postoperative outcomes. Results The patient population comprised 22 women (57.9%) and 16 men (42.1%), with a mean age of 34.9 years. A practical classification system based on the radiological–anatomical vertical (1, 2, and 3) and horizontal (a, b, and c) tumor extensions was designed. No significant differences were found in the patients in terms of sex/age. The most commonly observed symptom was gait disturbance (34.2%). The preoperative tumor diameter was significantly larger in the subtotal resection (STR) group than in the gross total resection (GTR) and near-total resection (NTR) groups. Significantly more cistern involvement was observed in the STR group than in the GTR group. The GTR, NTR, and STR rates were higher in grade 1, 3, and 2 cases, respectively. The subgroup ‘a’ was correlated with higher resection rates (GTR and NTR), whereas the subgroup ‘b’ was correlated with STR. Conclusions Our suggested classification system represents a simple and practical model that may guide neurosurgeons in predicting the goal of resection during surgical planning and in minimizing potential morbidity.

The impact of intra-operative magnetic resonance imaging and 5-ALA in the achievement of gross total resection of gliomas: A systematic literature review and meta-analysis.

In an effort to maximize extent of resection (EOR) regarding gliomas, intraoperative MRI (i-MRI) and 5-aminolevulinic acid (5-ALA) have been developed. Our study aimed to investigate the comparative contribution of 5-aminolevulinic acid and i-MRI in maximizing EOR in gliomas. We searched the PubMed and ScienceDirect services for randomized controlled trials, controlled trials and interrupted time series studies evaluating the effect of i-MRI on gross total resection (GTR) rates and on overall survival in glioma patients. Our primary study endpoint was the definition of the percentage of patients who were offered GTR. Other relevant points of interest included the determination of overall and progression-free survival and subgroup analyses for level of evidence. I-MRI aids in achieving GTR (odds ratio 2.71, p&lt;0.0001). Magnet field strength does not affect significantly either GTR rates (p=0.08). The cost of the procedure is dependent on the workload of the i-MRI system. These data suggest that i-MRI or 5-ALA improves progression-free and overall survival, although there are several restrictions related to their effectiveness and reliability. I-MRI and 5-ALA are considered to be effective adjuncts in the achievement of GTR of gliomas. When these methods are compared, there is no definite conclusion regarding which method is more effective.

Tuberculum Sellae Meningiomas: Transcranial Approaches Results and Complications

Objective: Tuberculum sellae meningiomas constitute about 5% - 10% of intracranial meningiomas. They are difficult to treat, owing to their close association with the optic nerves, chiasma, and major cerebral arteries. This retrospective study aims to report on the clinical outcome after transcranial approach for treatment of tuberculem sellae meningiomas at our hospital. Patients and Methods: We reviewed patients with tuberculem sellae meningiomas and underwent transcranial surgical approaches for their lesions at Sohag university hospitals over a 4 years period starting from January 2018. The patients’ clinical and radiological data, operative details, degrees of tumor removal, outcomes and complications were reported. Results: There were 17 patients with tuberculem sellae meningiomas with a mean age of 46.3 years. Female patients constituted 70% of cases. Pterional approach was used in 59% of cases and unilateral subfrontal approach was used in 41% of cases. Gross total tumor removal was achieved in 82% of cases. Visual acuity improved in 47%, remained unchanged in 41%, and worsened in 5.9% of patients. Transient post-operative diabetes inspidus and post-operative haematoma in tumor bed each occurred in 5.9% of patients. Conclusion: Transcranial removal of tuberculum sellae meningioma is still considered the standard approach, with high rate of gross total resection and better visual outcome and low mortality and morbidity.

Pattern of use of intraoperative ultrasound in surgery for brain tumors influences outcomes in glial tumors.

Background Intraoperative ultrasound (iUS) imaging has emerged as a promising adjunct in glioma surgery with both, 2-dimensional (2D) as well as navigated 3-dimensional (n3D), modes increasingly being used. Methods We analyzed our decade-long experience of 1075 brain tumor (807, 75% gliomas) cases operated using iUS. A retrospective chart and electronic records review was performed. The primary aim was to understand the patterns of use of iUS mode and its purpose of application (as a localizing tool or as a resection control modality) as well as to evaluate its impact on the extent of resection. Results The use of iUS increased over time, especially with the introduction of n3DUS though 2DUS remained the more commonly used mode (63%) overall during this period. For biopsies (156 cases), both 2D, as well as n3D iUS, were used as a localizing tool only. Lesion localization was the major purpose for use of iUS even for tumor resections (61%). Resection control was performed more often for gliomas (46.5% compared to 16.5% in non-glial tumors). n3DUS was the preferred modality as a resection control tool irrespective of histological class. GTR (gross total resection) was achieved in 53.1% cases overall, while in glial and non-glial tumors it was 44.7% and 80.7%, respectively. GTR was higher when iUS was used as a resection control modality. The US and MR defined EOR (extent of resection) showed substantial agreement (κ = 0.678) with high diagnostic accuracy of 84% for glial tumors. In glial tumors, iUS was used more often in eloquent tumors and GTR rates were slightly higher than when iUS was not used. Conclusion iUS is a versatile tool and is a useful surgical adjunct for glioma surgeons. Besides its proven benefit as a localizing tool, when used as a tool for resection control it improves the resection rates. n3DUS may offer benefits over 2DUS as a resection control modality, though the evidence is still evolving.

Endoscopic endonasal versus transcranial surgery for primary resection of craniopharyngiomas based on a new QST classification system: a comparative series of 315 patients.

An assessment of the transcranial approach (TCA) and the endoscopic endonasal approach (EEA) for craniopharyngiomas (CPs) according to tumor types has not been reported. The aim of this study was to evaluate both surgical approaches for different types of CPs. A retrospective review of primary resected CPs was performed. A QST classification system based on tumor origin was used to classify tumors into 3 types as follows: infrasellar/subdiaphragmatic CPs (Q-CPs), subarachnoidal CPs (S-CPs), and pars tuberalis CPs (T-CPs). Within each tumor type, patients were further arranged into two groups: those treated via the TCA and those treated via the EEA. Patient and tumor characteristics, surgical outcomes, and postoperative complications were obtained. All variables were statistically analyzed between surgical groups for each tumor type. A total of 315 patients were included in this series, of whom 87 were identified with Q-CPs (49 treated via TCA and 38 via EEA); 56 with S-CPs (36 treated via TCA and 20 via EEA); and 172 with T-CPs (105 treated via TCA and 67 via EEA). Patient and tumor characteristics were equivalent between both surgical groups in each tumor type. The overall gross-total resection rate (90.5% TCA vs 91.2% EEA, p = 0.85) and recurrence rate (8.9% TCA vs 6.4% EEA, p = 0.35) were similar between surgical groups. The EEA group had a greater chance of visual improvement (61.6% vs 35.8%, p = 0.01) and a decreased risk of visual deterioration (1.6% vs 11.0%, p < 0.001). Of the patients with T-CPs, postoperative hypothalamic status was better in the TCA group than in the EEA group (p = 0.016). Postoperative CSF leaks and nasal complication rates occurred more frequently in the EEA group (12.0% vs 0.5%, and 9.6% vs 0.5%; both p < 0.001). For Q-CPs, EEA was associated with an increased gross-total resection rate (97.4% vs 85.7%, p = 0.017), decreased recurrence rate (2.6% vs 12.2%, p = 0.001), and lower new hypopituitarism rate (28.9% vs 57.1%, p = 0.008). The recurrence-free survival in patients with Q-CPs was also significantly different between surgical groups (log-rank test, p = 0.037). The EEA required longer surgical time for T-CPs (p = 0.01). CPs could be effectively treated by radical surgery with favorable results. Both TCA and EEA have their advantages and limitations when used to manage different types of tumors. Individualized surgical strategies based on tumor growth patterns are mandatory to achieve optimal outcomes.

Delayed Facial Nerve Palsy Following Resection of Vestibular Schwannoma: Clinical and Surgical Characteristics.

Analyze delayed facial nerve palsy (DFNP) following resection of vestibular schwannoma (VS) to describe distinct characteristics and facial nerve (FN) functional course. Prospective cohort with retrospective review. Academic medical center. Consecutive patients undergoing VS resection 11/2017 to 08/2020. Exclusion criteria: preoperative House-Brackmann (HB) ≥ III, postoperative HB ≥ III without delayed palsy, <30 days follow-up. VS resection with intraoperative electromyographic monitoring. FN outcomes utilizing the HB scale; comparison between patients with DFNP (deterioration greater than one HB grade 24 hours to 30 days postoperatively) vs. those with HBI-II throughout. Two hundred eighty-eight patients met criteria: mean age 47.6 years, 36.1% male; 24.0% middle cranial fossa, 28.5% retrosigmoid, 47.6% translabyrinthine. DFNP occurred in 31 (10.8%) patients with average time to onset of 8.1 days. Of these, 22 (71.0%) recovered HBI-II and 3 (9.7%) recovered HBIII. Patients who experienced DFNP, on average, had larger maximum tumor diameter (23.4 vs. 18.7 mm, p = 0.014), lower rate of gross-total resection (54.8% vs. 75.5%, p = 0.014), and lower rate of ≥100 μV FN response to 0.05 mA stimulus intraoperatively (80.6% vs. 94.9%, p = 0.002). Compared to overall incidence of DFNP, translabyrinthine approach demonstrated higher incidence (15.3%, p = 0.017) while retrosigmoid lower (3.7%, p = 0.014). In multivariable logistic regression, patients with FN response ≥100 μV to 0.05 mA stimulus were 72.0% less likely to develop DFNP (p = 0.021). Intraoperative electromyographic facial nerve response, tumor size, surgical approach, and extent of resection may play a role in development of DFNP following resection of VS. Most patients who develop DFNP recover near-normal function.

Comparison of Endoscopic and Microscopic Transsphenoidal Approaches for the Resection of Pituitary Adenoma

Background: The comparative outcomes between endoscopic and microscopic transsphenoidal approaches (ETSA and MTSA) for pituitary adenomas (PAs) remain controversial; however, the numerous literatures have been investigated for decades. This study evaluated the effectiveness of these two techniques using comprehensive measurements and rigorous statistical methods. Methods: A retrospective review of patients who underwent transsphenoidal surgery for PAs at our institution between January 2010 and December 2019 was performed. We included only cases treated by surgeons who have independently performed more than 30 transsphenoidal surgeries. Patients’ characteristics, surgical outcomes, complications, and recurrence were collected for statistical analysis Results: A total of 210 patients, including 138 ETSA patients, and 72 MTSA patients, were analyzed. The baseline characteristics of the two groups were comparable. ETSA patients showed less intraoperative blood loss (191.9 mL vs. 369.9 mL, P &lt; 0.01), a higher rate of gross total resection (GTR) (84.1% vs. 72.2%, P = 0.04), a higher rate of extent of resection (EOR) (95.1% vs. 87.4%, P &lt; 0.01), and shorter hospital stay (10 days vs. 13.5 days, P &lt; 0.01). These better outcomes of ETSA persisted in multivariable regression analysis. Complications were not significantly different between groups. There was no statistical difference between recurrence-free survival of the two groups (P = 0.06, log-rank test) Conclusions: Our study showed that ETSA provided better outcomes and attained similar complications compared to MTSA for the resection of PAs.

Mid-term follow-up surgical results in 284 cases of clival chordomas: the risk factors for outcome and tumor recurrence

ObjectiveSkull base chordoma (SBC) is rare and one of the most challenging diseases to treat. We aimed to assess the optimal timing of adjuvant radiation therapy (RT) and to evaluate the factors that influence resection and long-term outcomes.MethodsIn total, 284 patients with 382 surgeries were enrolled in this retrospective study. Postsurgically, 64 patients underwent RT before recurrence (pre-recurrence RT), and 47 patients underwent RT after recurrence. During the first attempt to achieve gross-total resection (GTR), when the entire tumor was resected, 268 patients were treated with an endoscopic midline approach, and 16 patients were treated with microscopic lateral approaches. Factors associated with the success of GTR were identified using χ2 and logistic regression analyses. Risk factors associated with chordoma-specific survival (CSS) and progression-free survival (PFS) were evaluated with the Cox proportional hazards model.ResultsIn total, 74.6% of tumors were marginally resected [GTR (40.1%), near-total resection (34.5%)]. History of surgery, large tumor volumes, and tumor locations in the lower clivus were associated with a lower GTR rate. The mean follow-up period was 43.9 months. At the last follow-up, 181 (63.7%) patients were alive. RT history, histologic subtype (dedifferentiated and sarcomatoid), non-GTR, no postsurgical RT, and the presence of metastasis were associated with poorer CSS. Patients with pre-recurrence RT had the longest PFS and CSS, while patients without postsurgical RT had the worst outcome.ConclusionGTR is the goal of initial surgical treatment. Pre-recurrence RT would improve outcome regardless of GTR.

Endoscopic Endonasal Surgical Strategy for Skull Base Chordomas Based on Tumor Growth Directions: Surgical Outcomes of 167 Patients During 3 Years.

BackgroundSkull base chordomas (SBCs) are rare malignant bone tumors with dismal long-term local control. Endoscopic endonasal surgeries (EESs) are increasingly adopted to resect SBCs recently. Gross total resection (GTR) favors good outcomes. However, the SBCs often invade the skull base extensively and hide behind vital neurovascular structures; the tumors were challenging to remove entirely. To improve the GTR, we established a surgical strategy for EES according to the tumor growth directions.MethodsA total of 112 patients with SBCs from 2018 to 2019 were classified into the derivation group. We retrospectively analyzed their radiologic images and operation videos to find the accurate tumor locations. By doing so, we confirmed the tumor growth directions and established a surgical strategy. Fifty-five patients who were operated on in 2020 were regarded as the validation group, and we performed their operations following the surgical strategy to verify its value.ResultsIn the derivation group, 78.6% of SBCs invade the dorsum sellae and posterior clinoid process region. 62.5% and 69.6% of tumors extend to the left and right posterior spaces of cavernous ICA, respectively. 59.8% and 61.6% of tumors extend to the left and right posterior spaces of paraclival and lacerum ICA (pc-la ICA), respectively. 30.4% and 28.6% of tumors extended along the left and right petroclival fissures that extend toward the jugular foramen, respectively. 30.4% of tumors involved the foramen magnum and craniocervical junction region. The GTR was achieved in 60.8% of patients with primary SBCs in the derivation group. Based on the tumors’ growth pattern, pituitary transposition and posterior clinoidectomy techniques were adopted to resect tumors that hid behind cavernous ICA. Paraclival ICA transposition was used when the tumor invaded the posterior spaces of pc-la ICA. Lacerum fibrocartilage resection and eustachian tube transposition may be warranted to resect the tumors that extended to the jugular foramen. GTR was achieved in 75.0% of patients with primary SBCs in the validation group.ConclusionBesides the midline clival region, the SBCs frequently grow into the eight spaces mentioned above. The surgical strategy based on the growth pattern contributes to increasing the GTR rate.