Rate Of Gross Total Resection Research Articles

Endoscopic Versus Microscopic Transsphenoidal Surgery for Pituitary Tumors.

To compare the clinical outcomes and complications of 247 pituitary tumor patients managed by endoscopic and microscopic approaches in our hospital. The authors performed a retrospective review of 100 pituitary tumor patients treated by endoscopic endonasal transsphenoidal surgery (ETS) and 147 patients treated by microscopic transsphenoidal surgery (MTS) at our center from January 2007 to July 2014. The tumors were stratified by Knosp classification and modified Hardy classification, and tumor gross total resection (GTR)/remission rate, visual improvement rate, complications, operation time, intraoperative bleeding and length of hospital stay were compared between ETS and MTS. The GTR rate decreased with increasing Knosp grades for both ETS and MTS, with the rates of 93.3%, 87.5%, 71.4%, 58.8% for ETS and 82.8%, 92.0%, 70.7%, 36.0% for MTS in resecting Knosp grades 0, I, II, and III tumors, respectively. The visual improvement rates increased with increasing Hardy grades, which was 66.7% and 45.5% for Hardy grade B lesion, 72.2% and 71.4% for grade C lesion, and 88.9% and 78.9% for grade D lesion treated by ETS and MTS, respectively. No significant differences were observed for GTR rate, visual outcome and complication rate between ETS and MTS, while ETS resulted in more intraoperative blood loss, longer operative time, and shorter hospital stay than MTS. These data conclude that, compared with MTS, ETS needs longer operation time and results in more intraoperative blood loss, but appears to achieve higher GTR rate for Knosp grade III pituitary tumors.

Safety and outcomes of preoperative embolization of intracranial hemangioblastomas: A systematic review

IntroductionWhile preoperative embolization is often reserved for large and highly vascular tumors in order to minimize blood loss, its safety and efficacy in the treatment of hemangioblastomas (HB) is unclear. We present the largest systematic review focusing on the safety and outcome of preoperative embolization of intracranial HB. Materials and methodsTo identify all cases of preoperative embolization for HB, a literature search was conducted via Medline (OVID and PubMed), Scopus, Embase, and Web of Science. Studies that were in English, included intracranial hemangioblastomas treated with preoperative embolization and provided sufficient disaggregated clinical data for each patient were included. Historical control patients with non-embolized intracranial HB undergoing resection were similarly identified. ResultsA total of 111 patients that underwent preoperative embolization of HB prior to planned resection were identified. Patient age ranged from 12 to 72 years, with a cohort of 63% males and 36% females. Nine studies comprising 392 non-embolized patients were included as controls. Gross total resection was achieved in 83.7% of embolized and 95.6% of non-embolized patients. Intraoperative blood transfusion was required in 15.3% of embolized and 0.51% of non-embolized controls, while rates of post-operative hemorrhage were 8.4% and 1.6%, respectively. Complication rates from embolization were 11.7% and following consequent surgery were 20.7%. DiscussionEmbolization did not increase rates of gross total resection, decrease estimated blood loss, or decrease incidence of complications. Not only does embolization fail to mitigate surgical risks, the embolization procedure itself carries significant risk for complications. Embolization should not be standard of care for intracranial HB.

Endonasal Endoscopic Surgery for Recurrent Craniopharyngiomas Can Be Equally Effective as Initial Surgery and Ought to Be Offered before Contemplating Radiation

Background: Recurrent craniopharyngiomas have been offered radiation due to presumed higher rates of complications with surgery. The distinct importance of endonasal endoscopic surgery on recurrent craniopharyngiomas is not clear. Methods: From prospective database of endonasal endoscopic resection of craniopharyngiomas at WCMC/NYP, 22 recurrent cases were studied in comparison to 35 initial tumors. Prior radiation, visual, endocrine function, body mass index (BMI), quality of life (QOL), tumor volume, extent of resection and complications were compared between groups. Univariate and multivariate statistical analyses were performed. Results: Baseline hypopituitarism (82 vs. 60%) and DI (55 vs. 9%) were significantly more frequent with recurrent tumors (p < 0.001). Rates of gross total resection (GTR) were not significantly different between the two groups (90 vs. 97%). Larger and radiated tumors had lower GTR. Higher trend of postoperative pituitary dysfunction was noted in recurrent group (51 vs. 23% new anterior pituitary dysfunction, 80 vs. 47% new diabetes insipidus, p = 0.08). Vision improved equally in both groups (80 vs. 73%). There was no significant difference between the groups with respect to improvement in QOL at 1 year (7.5 vs. 14.5, p = 0.15) and increase in median BMI at 5 years (4.6 vs. 4.4 kg/m2, p = 0.69). Rates of further tumor regrowth were also similar (14 vs. 9%, p = 0.67). Conclusion: Endonasal endoscopic surgery for recurrent craniopharyngiomas results in comparable GTR, visual, QOL and BMI outcome as initial surgery, with no significant increase in complications. Only tumor volume and radiation impacted resection rates. Recurrent craniopharyngiomas ought to be offered endonasal surgery before contemplating radiation.

Coevolution of Peer-Reviewed Literature and Clinical Practice in High-Grade Glioma Resection

The paradigm of evidence-based medicine dictates that clinical practice should reflect the shifting landscape of the peer-reviewed literature. Here, we examined the extent to which this premise is fulfilled as it pertains to the surgical resection of high-grade gliomas (HGGs). We assessed trends in published literature regarding HGG survival after resection in conjunction with trends in clinical practice patterns of HGG resection. We performed a comprehensive PubMed search to identify articles that examined whether gross total resection (GTR) improves HGG survival. Temporal trends in the literature were compared with rates of GTR in the Surveillance Epidemiology and End Results (SEER) database, the Veterans Health Administration database, and published data series from academic neuro-oncology centers. Before 2000, the ratio of articles supporting survival benefit of GTR relative to those not supporting it ranged from approximately 1:5 to 1:1. Since 2000, this ratio has steadily increased such that by the post-2013 period, 32 of the 33 published articles (>30:1) supported the survival benefit of GTR. Although the frequency of GTR increased during the 2000-2004 period in the SEER and Veterans Health Administration database, no further increase in the frequency of GTR was observed thereafter. In contrast, resection rates in academic neuro-oncology centers continued to increase subsequent to2004. Our results indicate that clinical practice patterns mirror publication patterns for HGG resection, suggesting that neurosurgical oncology is a field in which clinical practice is informed by the peer-reviewed literature.

Correlation between intraoperative ultrasound and postoperative MRI in pediatric tumor surgery.

OBJECTIVE Malignant disease of the CNS is the primary etiology for deaths resulting from cancer in the pediatric population. It has been well documented that outcomes of pediatric neurosurgery rely on the extent of tumor resection. Therefore, techniques that improve surgical results have significant clinical implications. Intraoperative ultrasound (IOUS) offers real-time surgical guidance and a more accurate means for detecting residual tumor that is inconspicuous to the naked eye. The objective of this study was to evaluate the correlation of extent of resection between IOUS and postoperative MRI. The authors measured the correlation of extent of resection, negative predictive value, and sensitivity of IOUS and compared them with those of MRI. METHODS This study consisted of a retrospective review of the medical charts of all pediatric patients who underwent neurosurgical treatment of a tumor between August 2009 and July 2015 at Albany Medical Center. Included were patients who were aged ≤ 21 years, who underwent brain or spinal tumor resection, for whom IOUS was used during the tumor resection, and for whom postoperative MRI (with and without contrast) was performed within 1 week of surgery. RESULTS Sixty-two patients met inclusion criteria for the study (33 males, mean age 10.0 years). The IOUS results very significantly correlated with postoperative MRI results (φ = 0.726; p = 0.000000011; negative predictive value 86.3% [95% CI 73.7%-94.3%]). These results exemplify a 71% overall gross-total resection rate and 80% intended gross-total resection rate with the use of IOUS (i.e., excluding cases performed only for debulking purposes). CONCLUSIONS The use of IOUS may play an important role in achieving a greater extent of resection by providing real-time information on tumor volume and location in the setting of brain shift throughout the course of an operation. The authors support the use of IOUS in pediatric CNS tumor surgery to improve clinical outcomes at low cost with minimal additional operating-room time and no identified additional risk.

Neurological outcomes and surgical complications in 221 spinal nerve sheath tumors.

OBJECTIVE Among all primary spinal neoplasms, approximately two-thirds are intradural extramedullary lesions; nerve sheath tumors, mainly neurofibromas and schwannomas, comprise approximately half of them. Given the rarity of these lesions, reports of surgical complications are limited. The aim of this study was to identify the rates of new or worsening neurological deficits and surgical complications associated with the resection of spinal nerve sheath tumors and the potential factors related to these outcomes. METHODS Patients were identified through a search of an institutional neuropathology database and a separate review of current procedural terminology (CPT) codes. Age, sex, clinical presentation, presence of neurofibromatosis (NF), tumor type, tumor location, extent of resection characterized as gross total or subtotal, use of intraoperative neuromonitoring, surgical complications, presence of neurological deficit, and clinical follow-up were recorded. RESULTS Two hundred twenty-one tumors in 199 patients with a mean age of 45 years were identified. Fifty-three tumors were neurofibromas; 163, schwannomas; and 5, malignant peripheral nerve sheath tumors (MPNSTs). There were 70 complications in 221 cases, a rate of 32%, which included 34 new or worsening sensory symptoms (15%), 12 new or worsening motor deficits (5%), 10 CSF leaks or pseudomeningoceles (4%), 11 wound infections (5%), 5 cases of spinal deformity (2%), and 6 others (2 spinal epidural hematomas, 1 nonoperative cranial subdural hematoma, 1 deep venous thrombosis, 1 case of urinary retention, and 1 recurrent laryngeal nerve injury). Complications were more common in cervical (36%) and lumbosacral (38%) tumors than in thoracic (18%) lesions (p = 0.021). Intradural and dumbbell lesions were associated with higher rates of CSF leakage, pseudomeningocele, and wound infection. Complications were present in 18 neurofibromas (34%), 50 schwannomas (31%), and 2 MPNSTs (40%); the differences in frequency were not significant (p = 0.834). Higher complication rates were observed in patients with NF than in patients without (38% vs 30%, p = 0.189), although rates were higher in NF Type 2 than in Type 1 (64% vs 31%). There was no difference in the use of intraoperative neuromonitoring when comparing cases with surgical complications and those without (67% vs 69%, p = 0.797). However, the use of neuromonitoring was associated with a significantly higher rate of gross-total resection (79% vs 66%, p = 0.022). CONCLUSIONS Resection is a safe and effective treatment for spinal nerve sheath tumors. Approximately 30% of patients developed a postoperative complication, most commonly new or worsening sensory deficits. This rate probably represents an inevitable complication of nerve sheath tumor surgery given the intimacy of these lesions with functional neural elements.

Retrosigmoid-transtentorial approach for petroclival meningiomas: operative technique and clinical outcome

Petroclival meningiomas (PCMs) are technically challenging lesions. Although the standard retrosigmoid approach is one of the most effective approaches, this route may have some limitations for the tumors extending into the supratentorial region and middle cranial fossa. We provide a modified surgical technique called retrosigmoid-transtentorial approach (RTTA) to solve these problems. The feasibility and efficacy of the RTTA were studied, by analyzing neurological outcomes and considerations of surgical strategies. We analyzed 64 of 71 PCM patients (90.1 %). All 64 patients had epicenter of tumor in the posterior fossa with varying degrees of extension into the supratentorial area and/or the middle fossa. A conventional retrosigmoid craniotomy was performed following which the tentorium was incised from the attachment of tumor toward the free edge, which improved exposure to the petroclival region by offering additional operative room without resection of the adjacent part of the petrous bone. The rate of gross total resection was 71.9 %. There was no incidence of intraoperative death. One patient died in the postoperative phase. The postoperative permanent morbidity rate was 25.4 %. Follow-up was done with the mean time of 60.7 ± 47.5 months. There were 6 recurrence, 8 progression and 7 death cases and the mean KPS score was 83.2 ± 13.4 in the last follow up. The RTTA achieves the goal of applying a safe, quick, uncomplicated, and lesser invasive access to the petroclival region which is indicated for tumors located in the posterior fossa with some extension into the supratentorial area and/or the middle fossa.

Analysis of outcomes and learning curve of endoscopic transsphenoidal surgeries for 124 patients with pituitary adenomas

To investigate the outcomes of the Endoscopic transsphenoidal surgery for patients with pituitary adenomas, analyze the learning curve and provide reference for future surgeries. Retrospective analysis was carried out on 124 patients by endoscopic transsphenoidal surgery with a single neurosurgeon over a period spanning from January 2010 to January 2014 at Peking Union Medical College Hospital.The changes of endocrine and tumor imaging before and after surgery were analysed. Operative time and complication rates of one surgeon in the early period of learning curve were compared with that in later period. There were significant differences in Gross total resection (GTR) rate of pituitary adenomas with different sizes and different Knosp classifications (P<0.01, P<0.01). GTR rate of huge adenomas was significantly lower than that of macroadenoma and adenomas (P<0.05). GTR rate of Knosp 4 grade adenoma was significantly lower than that of Knosp 0-3 level (P<0.05). No significant difference in GTR among all types of functional pituitary adenomas and hormone levels after surgery was observed (P>0.05). In addition, no significant difference (P>0.05) in complications among different sizes, Knosp grade and type of pituitary adenomas was observed.GTR of Knosp 4 adenoma in later period of the learning curve was significantly higher than that in early period (P<0.05). Meanwhile the operative time was significantly lower than early period (P<0.05). Endoscopic transsphenoidal pituitary adenoma resection has the advantages of wider surgical field, higher GTR rate, less trauma, fewer complications and better life quality of patients.Through standardized learning, the GTR rate of the invasive pituitary adenomas can be improved.

Foramen magnum meningiomas: surgical results and risks predicting poor outcomes based on a modified classification.

OBJECTIVE This study aimed to evaluate neurological function and progression/recurrence (P/R) outcome of foramen magnum meningioma (FMM) based on a modified classification. METHODS This study included 185 consecutive patients harboring FMMs (mean age 49.4 years; 124 females). The authors classified the FMMs into 4 types according to the previous classification of Bruneau and George as follows: Type A (n = 49, 26.5%), the dural attachment of the lesion grows below the vertebral artery (VA); Type B (n = 39, 21.1%), the dural attachment of the lesion grows above the VA; Type C1 (n = 84, 45.4%), the VA courses across the lesion with or without VA encasement or large lesions grow both above and below the bilateral VA; and Type C2 (n = 13, 7.0%), Type C1 plus partial/total encasement of the VA and extradural growth. RESULTS The median preoperative Karnofsky Performance Scale (KPS) score was 80. Gross-total resection (GTR) was achieved in 154 patients (83.2%). Lower cranial nerve morbidity was lowest in Type A lesions (16.3%). Type C2 lesions were inherently larger (p = 0.001), had a greater percentage of ventrolateral location (p = 0.009) and VA encasement (p < 0.001), lower GTR rate (p < 0.001), longer surgical duration (p = 0.015), higher morbidity (38.5%), higher P/R rate (30.8%, p = 0.009), and poorer recent KPS score compared with other types. After a mean follow-up duration of 110.3 months, the most recent follow-up data were obtained in 163 patients (88.1%). P/R was observed in 13 patients (7.2%). The median follow-up KPS score was 90. Compared with preoperative status, recent neurological status was improved in 91 (49.2%), stabilized in 76 (41.1%), and worsened in 18 (9.7%) patients. The multivariate Cox proportional hazard regression model demonstrated Type C2 (HR 3.94, 95% CI 1.04-15.0, p = 0.044), nontotal resection (HR 6.30, 95% CI 1.91-20.8, p = 0.003), and pathological mitosis (HR 7.11, 95% CI 1.96-25.8, p = 0.003) as independent adverse predictors for tumor P/R. Multivariate logistic regression analysis identified nontotal resection (OR 4.06, 95% CI 1.16-14.2, p = 0.029) and pathological mitosis (OR 6.29, 95% CI 1.47-27.0, p = 0.013) as independent risks for poor outcome (KPS score < 80). CONCLUSIONS The modified classification helped to predict surgical outcome and P/R in addition to the position of the lower cranial nerves. Preoperative imaging studies and neurological function should be reviewed carefully to establish an individualized management strategy to improve long-term outcome.

Survival in glioblastoma: a review on the impact of treatment modalities.

Glioblastoma (GBM) is the most common and lethal tumor of the central nervous system. The natural history of treated GBM remains very poor with 5-year survival rates of 5%. Survival has not significantly improved over the last decades. Currently, the best that can be offered is a modest 14-month overall median survival in patients undergoing maximum safe resection plus adjuvant chemoradiotherapy. Prognostic factors involved in survival include age, performance status, grade, specific markers (MGMT methylation, mutation of IDH1, IDH2 or TERT, 1p19q codeletion, overexpression of EGFR, etc.) and, likely, the extent of resection. Certain adjuncts to surgery, especially cortical mapping and 5-ALA fluorescence, favor higher rates of gross total resection with apparent positive impact on survival. Recurrent tumors can be offered re-intervention, participation in clinical trials, anti-angiogenic agent or local electric field therapy, without an evident impact on survival. Molecular-targeted therapies, immunotherapy and gene therapy are promising tools currently under research.

Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging.

The aim of this study was to quantitatively assess the role of intraoperative high-field 3-T MRI (3T-iMRI) in improving the gross-total resection (GTR) rate and the extent of resection (EOR) in endoscopic transsphenoidal surgery (TSS) for pituitary adenomas. Radiological and clinical data from a prospective database were retrospectively analyzed. Volumetric measurements of adenoma volumes pre-, intraoperatively, and 3 months postoperatively were performed in a consecutive series of patients who had undergone endoscopic TSS. The quantitative contribution of 3T-iMRI was measured as a percentage of the additional rate of GTR and of the EOR achieved after 3T-iMRI. The cohort consisted of 50 patients (51 operations) harboring 33 nonfunctioning and 18 functioning pituitary adenomas. Mean adenoma diameter and volume were 21.1 mm (range 5-47 mm) and 5.23 cm(3) (range 0.09-22.14 cm(3)), respectively. According to Knosp's classification, 10 cases were Grade 0; 8, Grade 1; 17, Grade 2; 12, Grade 3; and 4, Grade 4. Gross-total resection was the surgical goal (targeted [t]GTR) in 34 of 51 operations and was initially achieved in 16 (47%) of 34 at 3T-iMRI and in 30 (88%) of 34 cases after further resection. In this subgroup, the EOR increased from 91% at 3T-iMRI to 99% at the 3-month MRI (p < 0.05). In the 17 cases in which subtotal resection (STR) had been planned (tSTR), the EOR increased from 79% to 86% (p < 0.05) and GTR could be achieved in 1 case. Intrasellar remnants were present in 20 of 51 procedures at 3T-iMRI and in only 5 (10%) of 51 procedures after further resection (median volume 0.15 cm(3)). Overall, the use of 3T-iMRI led to further resection in 27 (53%) of 51 procedures and permitted GTR in 15 (56%) of these 27 procedures; thus, the GTR rate in the entire cohort increased from 31% (16 of 51) to 61% (31 of 51) and the EOR increased from 87% to 95% (p < 0.05). The use of high-definition 3T-iMRI allowed precise visualization and quantification of adenoma remnant volume. It helped to increase GTR and EOR rates in both tGTR and tSTR patient groups. Moreover, it helped to achieve low rates of intrasellar remnants. These data support the use of 3T-iMRI to achieve maximal, safe adenoma resection.

Optical technologies for intraoperative neurosurgical guidance.

Biomedical optics is a broadly interdisciplinary field at the interface of optical engineering, biophysics, computer science, medicine, biology, and chemistry, helping us understand light-tissue interactions to create applications with diagnostic and therapeutic value in medicine. Implementation of biomedical optics tools and principles has had a notable scientific and clinical resurgence in recent years in the neurosurgical community. This is in great part due to work in fluorescence-guided surgery of brain tumors leading to reports of significant improvement in maximizing the rates of gross-total resection. Multiple additional optical technologies have been implemented clinically, including diffuse reflectance spectroscopy and imaging, optical coherence tomography, Raman spectroscopy and imaging, and advanced quantitative methods, including quantitative fluorescence and lifetime imaging. Here we present a clinically relevant and technologically informed overview and discussion of some of the major clinical implementations of optical technologies as intraoperative guidance tools in neurosurgery.

Surgical management of medium and large petroclival meningiomas: benchmark and limits

Da Li and co-workers present a detailed sub-analysis of their series of petroclival meningiomas, which is the largest monocentric series published to date [5, 6]. In the current work, they restrict the analysis to medium and large tumours of more than 2 cm in diameter—the tumours that really cause difficulties for microsurgery as well as stereotactic radiosurgery. Gross total resection was achieved in 56 % of patients; dysfunctions of the cranial nerves were the most common complication and occurred in two-thirds of the patients. Immediately following surgery, morbidity temporarily increased and the Karnovsky Performance Scale temporarily decreased on average. The case fatality rate amounted to 2 %. Permanent surgical morbidity remained in 20 % of patients during the average long-term follow-up of almost 10 years, but significantly more patients lived independently after than before surgery (61 vs 46 %). One-fourth of patients were lost to longterm follow-up, so that the numbers regarding long-term outcome must be appreciated with sound judgment. These key data focusing on medium and large petroclival meningioma are important, although difficult to compare with the smaller unselected series [1, 3, 7–9, 12]. Petroclival meningiomas smaller than 2 cm carry a much smaller surgical risk than large tumours, and in unselected series the small tumours dilute information regarding the problematic larger tumours. Numbers for the rate of gross total resection and surgical morbidities given in the published unselected series differ widely: gross total resection between one-third and twothirds, and surgical morbidity also between one-third and twothirds. Stereotactic radiosurgery is an obvious alternative for primary treatment of these tumours. There are not very many reports—a fact that reflects concerns regarding tolerance in view of the vicinity of the brainstem. The Pittsburgh group reported their experience in a series of 39 patients with a median follow-up period of 37 months. Neurological status improved in 21 %, remained stable in 66 %, and eventually worsened in 13 %. Tumour volumes decreased in 23 %, remained stable in 68 % and increased in 8 % [13]. It appears that there is some kind of consensus that radiosurgery is an adjuvant modality for larger petroclival meningiomas, which cannot be recommended as first-line therapy. However, there is little doubt that in analogy to vestibular schwannomas, stereotactic radiosurgery has evolved to an alternative for smallsized meningiomas. The substantial proportion of incomplete removal in most series and the significant rate of morbidity suggest that petroclival meningiomas remain not only difficult but basically problematic for microsurgery. Finding the balance between radicality and risk is the real challenge of managing petroclival meningiomas. The surgical risk appears to be influenced by (1) tumour size, (2) consistency and texture of the tumour and (3) the interface between tumour and arteries, brainstem and cranial nerves. In my opinion, it is hardly possible to dissect an adherent or even encased pontine artery from the tumour. Better presurgical imaging should provide more information with regard to tumour consistency and interface to vital structures. The techniques to define mechanical properties are partially already available, but they must be integrated into clinical routine [10, 11, 15]. The techniques to define interfaces are also available with the heavily contrasted T2* Hans-Jakob Steiger steiger@uni-duesseldorf.de

Management and outcomes of intramedullary spinal cord tumors: A single center experience from a developing country.

Background:Intraoperative neurophysiology, high magnification microscopes, and ultrasonic aspirators are considered essential aid for the safe resection of intramedullary spinal cord tumors (IMSCTs). Most centers in developing countries such as Pakistan still lack these facilities. The purpose of this study was to review the management of IMSCTs at our hospital and to determine factors associated with the outcomes of surgery.Methods:This was a retrospective review of medical records of adult patients undergoing surgery for IMSCT over 12 years. The institutional ethical review committee approved this study. Data were collected regarding demographics, clinical and radiological features, and surgical details. Modified McCormick Scale was used to grade patients’ neurological status at admission, discharge, and follow-up. Statistical analysis was performed using the Statistical Package for Social Sciences version 22.Results:Forty three cases were reviewed. Mean age was 33.8 ± 15.1 years whereas median follow-up was 5 months (range: 0.25–96 months). Most patients had ependymoma (n = 16; 73%). Cervical region was the most commonly involved (n = 15; 34.9%). Gross total resection (GTR) was achieved in 30 cases (69.8%). The preoperative McCormick grade was significantly associated with follow-up McCormick grade (P value = 0.002). Eight patients (18.6%) underwent intraoperative electrophysiological monitoring, out of which GTR was achieved in all cases, and none had disease progression or recurrence. Ten patients received postoperative radiotherapy. Thirty five patients (81.4%) had progression free survival at last follow-up.Conclusions:We achieved a GTR rate of 68.9% for IMSCTs with limited resources. In few cases, where intraoperative electrophysiology was used, the rate of GTR was 100%. Preoperative neurological status was associated with better postoperative McCormick score.

Fluorescein Sodium-Guided Surgery of Malignant Brain Tumors: History, Current Concepts, and Future Project.

Fluorescein sodium (FL)-guided resection has become an important and beneficial treatment method for malignant brain tumors. FL-guided resection improves the rate of gross total resection in high-grade gliomas (HGG) and cerebral metastases (CM). FL sensitively visualizes the disruption of the blood-brain barrier in the area surrounding malignant lesions, similar to contrast-enhanced T1-weighted MR sequences. This review of the current literature summarizes the history of FL in neurosurgery from 1946 until today. We discuss the molecular mechanism of FL accumulation in cerebral malignant tumors and provide an overview of the current practice of using FL and applying a dedicated surgical microscope filter. Additionally, we outline and discuss ongoing trials and future projects.

Surgical strategy in the management of low-grade brain neoplasm with epilepsy: seizure outcome

Background For 30-50% of patients with brain tumors, epileptic seizures are the presenting clinical sign of a tumor; 10-30% of patients develop seizures later during the disease course. Slow-growing tumors, (i.e. low-grade gliomata) are the most epileptogenic, although the high frequency of epilepsy in these patients might be related to longer survival from low-grade tumors. This study bears on this controversy through a prospective strategy in which patients were treated with excision of lesion together with epileptogenic area around, as defined using intraoperative electrocorticography. Patients and methods This is a prospective study designed to treat patients presenting between January 1997 and December 2011 with drug-resistant epilepsy (defined as failure to attain a seizure-free status utilizing adequate trials of two tolerated and appropriate antiepileptic drugs). Surgical procedure consisted of maximal resection of the tumor and any resectable surrounding associated with epileptogenic cortex, identified by means of intraoperative electrocorticography. Results Fifty-four patients were operated upon and followed up for a mean of 40 months (range = 6-72 months). Thirty-two tumors (59.2%) were located in the temporal lobe, 15 (27.8%) in the frontal lobe, and seven (13%) in the parietal lobe. The histopathology confirmed low-grade astrocytoma (WHO grade I or II) in 38.9% ( n = 21) of patients, oligodendroglioma in 24% ( n = 13), ganglioglioma in 20.4% ( n = 11), and dysembryoplastic neuroepithelial tumor in 16.7% ( n = 9) of patients. Gross total resection was achieved in 64.8% ( n = 35) of patients and subtotal resection in 35.2% ( n = 19) of patients. There was no death and five patients had permanent deficit. At follow-up, according to Engel's seizure outcome scale, 77.8% ( n = 42) of the patients had good seizure control (classes I and II), and, collectively, 90.7% ( n = 49) of patients had more than 75% reduction in seizures (class I-III). Conclusion In our series, we had a relatively high rate of gross total resection, which was associated with worthwhile seizure control, which compares favorably with a recent work that showed that the extent of resection significantly predicts seizure freedom following surgery. The favorable seizure outcome is tentatively attributed to the fact that all identified areas harboring epileptogenic activity around tumors were resected along with tumor resection.

Endoscopic skull base surgery: evaluation of current clinical outcomes.

Endoscopic skull base surgery is one of the most recent fields of neurosurgery. Successive innovations were developed throughout history so that the current concepts that rule this surgical field could be reached. The current paper presents the evolution of endoscopic surgery and its current results on the treatment of skull base tumor, based on a review of meta-analysis and clinical series. A PubMed search for articles published between January 1990 and January 2014 about "endoscopic skull base surgery", "endoscopic transsphenoidal approach", "endoscopic treatment of parasellar tumors" and "suprasellar lesions" was performed. According to the current data, endoscopic surgery seems to be superior to open and transsphenoidal microscopic removal of giant pituitary adenomas. Endoscopy is at least as successful as transsphenoidal microsurgery for the removal of pituitary adenomas and craniopharyngiomas. Transcranial open approaches, in the context of anterior midline skull base meningiomas, present higher rates of gross total resection, fewer complications and better clinical results than endoscopy approaches. The rate of postoperative CSF leakage has been significantly reduced with the introduction of new techniques such as the Hadad-Bassagasteguy flap but still represent one of the most important complications of this technique. Currently, selected tumors located at the anterior, middle and posterior fossa can be adequately assessed using the endoscope with low rates of postoperative CSF leaks. Endoscopic surgery has substantially evolved in the last decades through the collaboration of different teams around the world. The endoscope is now an essential tool in the neurosurgery armamentarium with great potential for new applications in the nearby future.

Role of preoperative embolization for intradural spinal hemangioblastomas

Spinal hemangioblastomas (HB) are relatively rare neoplasms with a high degree of vascularity. Therapy for symptomatic tumors involves total resection when possible. Due to the enriched blood supply of these neoplasms, there is a high risk of significant intraoperative blood loss, which can lead to perioperative complications. Preoperative embolization of HB has been suggested to reduce blood loss and operative morbidity, but its use remains controversial. Data on the risks and benefits of preoperative embolization for this tumor remains limited. We identified and analyzed all 29 reported cases of preoperative embolization of intradural spinal HB within the literature. There were 18 men and nine women, and patients ranged from 24 to 61years of age. Mean tumor size was 3.5cm. Cervical and thoracic location was most common, accounting for 48.3% and 20% of cases, respectively. Complications from embolization and surgery were minimal, with no deaths or permanent neurological morbidity. Minimal intraoperative bleeding and excellent rates of gross total resection were reported with preoperative embolization. However, outcomes from microsurgery alone from historical series have similarly reported excellent outcomes. While there is no established standard, preoperative embolization should be reserved for particularly high risk patients with risk of intraoperative bleeding.

Review of seizure outcomes after surgical resection of dysembryoplastic neuroepithelial tumors.

Dysembryoplastic neuroepithelial tumors (DNETs) are rare tumors that present with seizures in the majority of cases. We report the results of a review of seizure freedom rates following resection of these benign lesions. We searched the English literature using PubMed for articles presenting seizure freedom rates for DNETs as a unique entity. Patient demographics, tumor characteristics, and operative variables were assessed across selected studies. Twenty-nine articles were included in the analysis. The mean age at surgery across studies was a median of 18 years (interquartile range 11-25 years). The mean duration of epilepsy pre-operatively was a median 7 years (interquartile range 3-11 years). Median reported gross-total resection rate across studies was 79% (interquartile range 62-92%). Authors variously chose lesionectomy or extended lesionectomy operations within and across studies. The median seizure freedom rate was 86% (interquartile range 77-93%) with only one study reporting fewer than 60% of patients seizure free. Seizure outcomes were either reported at 1 year of follow-up or at last follow-up, which occurred at a median of 4 years (interquartile range 3-7 years). The number of seizure-free patients who discontinued anti-epileptic drugs varied widely from zero to all patients. Greater extent of resection was associated with seizure freedom in four studies.

Endoscopic Endonasal Transsphenoidal Treatment of Pituitary Apoplexy: Outcomes in a Series of 20 Patients.

Objective: Pituitary apoplexy is a rare clinical entity and few cases treated with an endonasal endoscopic approach (EEA) have been reported. We report our experience of treating pituitary apoplexy using an EEA approach.Methods: We performed a retrospective chart review on all the patients who underwent EEA skull base and pituitary surgery between December 2003 and March 2012 performed by the senior authors (THS and VKA) and identified patients with pituitary apoplexy. The extent of resection was determined volumetrically and the visual and endocrine outcome was evaluated. Results: From a total of 488 skull base surgeries, there were 241 pituitary cases, of which 20 had apoplexy. The most common presenting symptoms included headaches (80%), endocrinopathy (95%), and visual symptoms (60%). Surgery was performed within 24 hours in 15% of patients, and > one month after ictus in 40% due to late referral. Gross-total resection (GTR) was achieved in 18 (90%) patients. There was one (5%) postoperative cerebrospinal fluid (CSF) leak treated with lumbar drainage. Of 12 patients with preoperative visual disturbances, seven had improvements. For those patients with visual field cuts, only 33.3% showed improvement. There was no postoperative visual deterioration. Two patients developed new transient postoperative diabetes insipidus (DI) but there was no new permanent DI. The mean duration of follow-up was 22 months (range: 6 days – 72 months).Conclusion: The endoscopic endonasal transsphenoidal approach is an effective modality to treat pituitary apoplexy with a high rate of GTR and minimal risk. Delayed surgery may result in lower rates of visual field defect improvement.