World Neurosurg Research Articles

6566 Concurrent Papillary Craniopharyngioma and Growth Hormone-Secreting Pituitary Adenoma: A Rare Collision Tumor

Abstract Disclosure: A.J. Mancini: None. R. Mathew: None. J. Oentoro: None. A.M. Devine: None. C. Maxwell: None. I. Kravets: None. Introduction: Collision tumors, which consist of two or more histologically distinct tumors in the same anatomic location, are rare; when occurring in the sella, they more commonly consist of a pituitary adenoma and Rathke cleft cyst. Here, we present a case of a collision tumor consisting of a papillary craniopharyngioma and GH-secreting pituitary adenoma. Clinical Case: A 49-year-old man presented with two months of headaches and blurry vision. Physical exam showed frontal bossing, enlarged jaw and hands, and macroglossia. A visual field exam revealed bitemporal hemianopsia. Initial labs included PRL 105.2 ng/mL (4.0-15.2), TSH 0.399 uIU/mL (0.27-4.2), free T4 0.95 ng/dL (0.93-1.70), FSH 0.8 mIU/mL (1.5-12.4), LH 0.3 mIU/mL (1.7-8.6), total testosterone 10 ng/dL (300-890) drawn at 6:00 a.m., cortisol 8.5 ug/dL (6.0-18.4) and ACTH 32.1 pg/mL (7.2-63.3) drawn at 10:30 a.m.; an IGF-1 was not initially sent. Pituitary MRI showed a 4.1 cm mixed solid and cystic sellar/suprasellar mass with mass effect on the optic chiasm. The patient underwent a craniotomy with tumor resection on hospital day (HD) 5 with pathology showing a papillary craniopharyngioma. The next week, an elevated IGF-1 level of 517 ng/mL (68-225) prompted a GH suppression test. GH levels 1 and 2 hours after oral glucose load were 19.3 ng/mL (0.05-3.00) and 17.8 ng/mL respectively, confirming the diagnosis of acromegaly. On HD 20, repeat MRI showed an interval increase in the mass size with increased mass effect on the optic chiasm. A second craniotomy with an endoscopic resection of the mass was performed, with pathology again showing a papillary craniopharyngioma. Post-operative MRI showed a residual mass with mild mass effect on the optic chiasm for which the patient began radiation therapy. Interval MRI demonstrating a further increase in the tumor size plus a rising IGF-1 level of 700 ng/mL and ongoing lack of GH suppression with an oral glucose load prompted a transsphenoidal resection of the tumor on HD 54. The pathology showed a growing residual papillary craniopharyngioma and a component of a PIT1 lineage adenoma, the majority of which expressed GH. The patient developed numerous complications during his hospitalization and ultimately passed away on HD 64. Conclusion: There are 22 reported cases of collision tumors of pituitary adenomas and craniopharyngiomas, and only five secreted GH. Moreover, four of the five cases described collision tumors with an adamantinomatous craniopharyngioma; the fifth case did not include data on the type of craniopharyngioma (1). Therefore, to the best of our knowledge, our case represents the first collision tumor of a GH-secreting pituitary adenoma and papillary craniopharyngioma. Reference: (1) Hasegawa H, Jentoft ME, Young WF, et al. Collision of Craniopharyngioma and Pituitary Adenoma: Comprehensive Review of an Extremely Rare Sellar Condition. World Neurosurg. 2021;149:e51-e62. Presentation: 6/3/2024

Sudden Death Due to Necrotizing Fasciitis After Routine Cervical Radiofrequency Ablation Treatment.

Cervical facet joint neurotomy, also known as cervical radiofrequency ablation (RFA) or cervical facet rhizotomy, is a medical procedure aimed at alleviating chronic neck pain caused by issues related to the cervical facet joints through ablation of neurons (J Pain Res 2021;14:2807-2831). Although generally safe, adverse events can occur. Infection is a rare consequence of this procedure. Most injection-site infections related to cervical RFA occur spontaneously and resolve with oral antibiotics without sequelae (World Neurosurg 2018;111:e644-e648). We report a case in which a cervical RFA injection resulted in the development of necrotizing fasciitis and ultimately death. To our knowledge, this has not been previously reported and is the first documented fatality due to infectious sequelae of a cervical RFA procedure.

Bibliometric and Visualization Analysis of Research Hotspots and Frontiers in Endoscopic Lumbar Discectomy.

The increasing utilization of endoscopic lumbar discectomy (ELD) in spinal surgery has sparked widespread interest and research. This study utilizes bibliometric analysis to identify current research trends and advancements in this innovative surgical technique, with the goal of informing and improving surgical practices. We retrieved relevant literature on ELD from the Science Citation Index Expanded (SCI-Expanded) within the Web of Science Core Collection (WoSCC) database as research samples. Various visualization tools, such as VOSviewer, CiteSpace, Scimago Graphica, Pajek, and online bibliometric platform, were employed to generate scientific knowledge maps for the purpose of visual presentation and data analysis. Over the past two decades, there has been significant progress in the research related to ELD, particularly since 2016. China has emerged as the most productive country, while South Korea and the United States have exerted greater academic influence. Tongji University has contributed the highest number of research output, while academic achievements published by Wooridul Spine Hospital are highly esteemed by scholars. Lee SH and Ruetten S are the most prolific author and the most highly cited author, respectively. World Neurosurg has published the highest number of publications, while Spine has become the most influential journal. Clinical Neurology and Surgery are the primary subject categories. Research in this field primarily revolves around improving ELD techniques, evaluating postoperative efficacy and prognosis prediction, studying complications and risk factors, as well as comparative research with other surgical techniques. Keywords such as risk factors, LDH, PETD, lumbar spinal stenosis, degeneration, recurrent herniation, laminectomy, local anesthesia, and foraminoplasty highlight the current research hotspots and future cutting-edge trends. This study employed bibliometric analysis to elucidate the research hotspots and frontiers in ELD. The findings have significant implications for advancing research and development in this field.

Purely Endoscopic Supracerebellar Infratentorial Approach to the Pineal Region in Pediatric Population.

Pineal lesions represent less than 1% of all brain tumors (Villani et al., Clin Neurol Neurosurg 109:1-6, 2007). The abysmal location and critical neurovascular structures remain a surgical challenge, despite the advent of microneurosurgery. The classical wide surgical suboccipital craniotomy with the supracerebellar infratentorial approach, described by Sir Victor Horsley (Victor, Proc R Soc Med 3:77-78, 1910), is infamous for its considerable surgical morbidity and mortality. This was later upgraded microneurosurgically by Stein to improve surgical outcomes (Stein, J Neurosurg 35:197-202, 1971).Ruge et al. reported the first purely endoscopic fenestration of quadrigeminal arachnoid cysts via this corridor (Ruge et al., Neurosurgery 38:830-7, 1996). A cadaver-based anatomical study by Cardia et al. demonstrated the viability for endoscope-assisted techniques (Cardia et al., J Neurosurg 2006;104(6 Suppl):409-14). However, the first purely endoscopic supracerebellar infratentorial (eSCIT) approach to a pineal cyst was performed in 2008 by Gore et al. (Gore PA et al., Neurosurgery 62:108-9, 2008).Unlike transventricular endoscopy, eSCIT approach poses no mechanical risk to the fornices and can be utilized irrespective of ventricular size. More vascular control and resultant reduction in uncontrolled hemorrhage improve the feasibility of attaining complete resection, especially around corners (Zaidi et al,, World Neurosurg 84, 2015). Gravity-dependent positioning and cerebrospinal fluid (CSF) diversion aid cerebellar relaxation, creating the ideal anatomical pathway. Also, angle of the straight sinus, tentorium, and tectal adherence can often influence the choice of approach; thus direct endoscopic visualization not only counteracts access to the engorged Galenic complex but also encourages sharp dissection of the arachnoid (Cardia et al., J Neurosurg 104:409-14, 2006). These tactics help provide excellent illumination with magnification, making it less fatiguing for the surgeon (Broggi et al., Neurosurgery 67:159-65, 2010).The purely endoscopic approach thwarts the dreaded risk of air embolisms, via simple copious irrigation from a small burr hole (Shahinian and Ra, J Neurol Surg B Skull Base 74:114-7, 2013). The tiny opening and closure are rapid to create, and the smaller wound decreases postoperative pain and morbidity. Recent literature supports its numerous advantages and favorable outcomes, making it a tough contender to traditional open methods.

Endovascular treatment of distal middle cerebral artery dissecting aneurysm with intracerebral hemorrhage in a paediatric patient: a case report and literature review

BackgroundIntracranial arterial aneurysms in the paediatric age group constitute less than 5% of all aneurysms. The most common form is spontaneous dissecting aneurysms (SDAs) (Peron et al. in Acta Neurochir 152(9):1511–1517, 2010; Huang et al. in Surg Neurol 63(5):424–432, 2005; Krishna et al. in Acta Neurochir 147(5):469–476, 2005; Ihn and Jung in J Korean Soc Radiol 65(5):441–445, 2011). It occurs most commonly in the posterior circulation and rarely in the anterior circulation, including the middle cerebral artery (MCA) (Chuang et al. in Asian J Surg 35(1):42–48, 2012; Ozaki et al. in World Neurosurg 113:208–211, 2018). MCA dissecting aneurysm even rarely presents with intracerebral haemorrhage (Ete et al. in J Case Rep 3(2):451–454, 2013; Ahmad in Interdiscip Neurosurg 18:100510, 2019; Bartoš et al. in Brain Sci 11(1):29, 2020).Case descriptionA 12 years old non-diabetic, non-hypertensive female presented with distal right MCA (M2-M3 junction) dissecting aneurysm with right parieto-temporal haemorrhage. The patient was well managed with endovascular coil embolization with a good functional outcome.ConclusionEndovascular coil embolization had favourable clinical and angiographic outcomes in distal MCA dissecting aneurysms.

Acute spontaneous intracerebral haemorrhage: does a care bundle approach work?

A care bundle is a small but crucial set of treatments that, when implemented together, can improve outcomes. 1 NHS Modernisation Agency10 high impact changes for service improvement and delivery: a guide for NHS leaders. http://www.nursingleadership.org.uk/publications/HIC.pdfDate: 2004 Date accessed: April 24, 2023 Google Scholar Acute spontaneous intracerebral haemorrhage has few effective treatments and intracerebral haemorrhage-specific recommendations for care bundles. 2 Parry-Jones AR Sammut-Powell C Paroutoglou K et al. Intracerebral hemorrhage care bundle is associated with lower case fatality. Ann Neurol. 2019; 86: 495-503 Crossref PubMed Scopus (40) Google Scholar , 3 Middleton S McElduff P Ward J et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet. 2011; 378: 1699-1706 Summary Full Text Full Text PDF PubMed Scopus (266) Google Scholar In clinical practice, intracerebral haemorrhage is often approached with negativity. 4 Willie JT Gross RE Beyond therapeutic nihilism? The neurosurgical treatment of intracerebral hemorrhage. World Neurosurg. 2013; 80: e135-e137 Crossref PubMed Scopus (1) Google Scholar Moreover, the synergistic benefits of specialised nursing care, neurointensive and neurosurgical care, blood pressure control, reversal of coagulopathy, and other interventions have not been ascertained. 5 Greenberg SM Ziai WC Cordonnier C et al. 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022; 53: e282-e361 Crossref PubMed Scopus (107) Google Scholar The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trialImplementation of a care bundle protocol for intensive blood pressure lowering and other management algorithms for physiological control within several hours of the onset of symptoms resulted in improved functional outcome for patients with acute intracerebral haemorrhage. Hospitals should incorporate this approach into clinical practice as part of active management for this serious condition. Full-Text PDF Open Access

623 Improving Access to Extracranial-Intracranial Bypass Surgery in Border Hispanic Communities Utilizing Collaborative Approach Between Plastics and Neurological Surgery

INTRODUCTION: Hispanic patients such as those with Moyamoya disease are less likely to receive surgical revascularization therapy due to inequities in access (1). Our institution is a located in the Southern Texas-Mexico border region serving a largely Hispanic population. We previously referred patients for EC-IC bypass to other quaternary-care centers in Texas. While referrals were already challenging due to distance, mixed immigration status, and poor socioeconomic background of many patients; COVID-19 further exacerbated this problem with restriction of elective surgical volume. METHODS: A consecutive series of EC-IC bypasses performed by authors (SKD and MDLG) were retrospectively reviewed. Baseline clinical, perioperative radiographic, and post-operative outcomes were studied. All patients were offered option of a referral to a quaternary-care centers and also given local option for performing bypass surgery. Further, patients met preoperatively with both the plastic and neurological surgeon. Ultimately, decision was made by patient. RESULTS: A total of 6 craniotomies for EC-IC bypass were performed during the study period. The diagnoses included Moyamoya in 5 cases and symptomatic intracranial atherosclerosis in one. All patients were Hispanic, female, and nonsmokers with mean age of 35.6 years. Mean preoperative HBa1c was 7.9, preoperative LDL was 82, and mean preoperative hemoglobin was 11.3. Direct bypass was performed in 40% of cases. Mean OR time was 3 hours and 7 minutes. CONCLUSIONS: We have found collaboration between plastic and neurological surgery for surgical revascularization is feasible and improved access to care for Hispanic Moyamoya disease patients residing in a border community. References 1) Chiu R, Chaker A, McGuire LS, et al. “Socioeconomic Inequities in the Surgical Management of Moyamoya Disease.” World Neurosurg. 2021 Nov; 155: e188-e195.

Spontaneous Near-Resolution of a Rathke’s Cleft Cyst

•Spontaneous near resolution of Rathke’s cleft cyst can occur•Conservative approach is recommended in the absence of mass effect or visual disturbance•The mechanism of spontaneous near resolution of RCC is poorly understood A 70-year-old Caucasian woman with history of chronic sinusitis presented to the Emergency department with 2-week history of headaches. Her physical examination was unremarkable including absence of galactorrhea, abnormal hair growth, or skin changes. Neurologic exam including visual fields were normal. Brain MRI revealed a 1.2 x 1.4x 1.3 cm ovoid, non-enhancing, cyst-like lesion with intrasellar and suprasellar components (Figure 1) with slight elevation and splaying of the optic chiasm and depression of the sella floor. Hormonal testing revealed normal values (Table 1). A conservative approach was chosen given the patient’s age, the lesion size, and lack of visual compromise or hormonal dysfunction.Table 1HormoneResultNormal RangeTSH0.90.280 – 3.980 ng/dlFree T40.600.58-1.64 ng/dlIGF-13741-279 ng/mlGrowth Hormone0.9<7.1 ng/mlProlactin19.272.74-19.64 ng/mLCortisol16.67-9a.m 4.0-22.0 mcg/dl Open table in a new tab At 1 month follow up she denied new symptoms. Repeat hormonal panel revealed a low FT4 0.5, and normal TSH 3.93, which prompted initiation of levothyroxine. The rest of the panel remained normal. A follow-up brain MRI revealed a hypoenhancing lesion within the sella with suprasellar extension measuring 1.1x 1.3 x0.9 cm (figure 2), contacting the optic chiasm without displacement. Ophthalmology evaluation reported normal visual fields. Neurosurgery recommended medical management. A year after initial presentation, TSH and Ft4 were normal on levothyroxine. Brain MRI revealed complete resolution of the previously characterized cystic lesion, with a normal-sized and shaped pituitary gland (figure 3). Patient continued to have intermittent headaches that were attributed to chronic sinusitis. The patient has not returned for a follow up visit, and we have been unable to reassess her pituitary/thyroid axis. What is the diagnosis? Answer: The clinical course and imaging findings are best explained by a rare case of a Rathke’s Cleft Cyst (RCC), with near spontaneous resolution. RCC are remnants of a failed regression of the developmental ectodermal pouch, characterized by unpredictable natural histories that can include spontaneous enlargement or less commonly decrease in size. The latter has been observed in up to 15% in studies evaluating the evolution and volumetry analysis of RCC (1Barkhoudarian G. Palejwala S.K. Ansari S. Eisenberg A.A. Huang X. Griffiths C.F. et al.Rathke’s cleft cysts: a 6-year experience of surgery vs. observation with comparative volumetric analysis.Pituitary [Internet]. 2019; 22 (Available from:): 362-371https://doi.org/10.1007/s11102-019-00962-yCrossref PubMed Scopus (19) Google Scholar). Symptoms may include headaches, pituitary dysfunction, and visual deficits from mass effect (2Altuwaijri N, Cote DJ, Lamba N, Albenayan W, Ren SP, Zaghloul I, et al. Headache Resolution After Rathke Cleft Cyst Resection: A Meta-Analysis. World Neurosurg [Internet]. 2018;111:e764–72. Available from: https://doi.org/10.1016/j.wneu.2017.12.170Google Scholar). There are no standardized management guidelines, however a conservative approach is preferred when there is absence of mass effect or visual disturbance as seen here(3Truong L.U.F. Bazin C. Gomis P. Decoudier B. Delemer B. Litré C.F. Surgery versus conservative care for Rathke’s cleft cyst.Neurochirurgie. 2021; 67: 104-111Crossref PubMed Scopus (4) Google Scholar). The mechanism of spontaneous resolution of RCC is poorly understood. This is a rare case of spontaneous near resolution of RCC in a patient that was followed by conservative therapy with regular clinical and radiologic follow up.

PMON129 Pituitary Adenoma Co-Secreting GH, Prolactin and ACTH

Abstract Background Pituitary adenomas co-secreting GH, Prolactin and ACTH are rare. Clinical Case A 38-year-old male with a past medical history of depression and type 2 diabetes mellitus was seen in the endocrinology clinic for an evaluation of acromegaly. In the preceding four years, the patient had experienced an enlargement of his hands and feet, hyperhidrosis, development of an underbite, snoring, daytime somnolence, erectile dysfunction, headaches, and blurry vision. His visual fields were normal. Physical exam: BP 137/85, BMI 39 kg/m2. He had coarse facial features, acral changes of his hands and feet, and wide spacing of his teeth. There was a notable absence of facial plethora, abdominal obesity with thin extremities, proximal muscle weakness, purple abdominal striae, and galactorrhea. Initial laboratory results: GH 16.9 ng/mL (0.05-3 ng/ml), IGF-1 1,109 ng/mL (82-242 ng/mL), Prolactin (PRL) 96.9 ng/ml (5-20 ng/ml), testosterone 34 ng/dL (200-1000 ng/dL), LH 2.3 miu/ml (1.4–12 miu/ml), FSH 4.8 miu/ml (1.5-12 miu /ml), ACTH 197.6 pg/mL (7.2- 63.3 pg/mL), 0800 cortisol 16.2 ug/dL (5-29 ug/dL), 24-hour urine free cortisol 56.84 mcg (3.5-40 mcg), HS salivary cortisol 0.242 (&amp;lt;0.359 ug/dL), overnight 1 mg Dexamethasone suppression test cortisol 6.9 mcg/dL (&amp;lt; 1.8 mcg/dL), normal Free T4 and TSH, and A1c 9.7%. A pituitary MRI revealed a 3.9 cm lobulated, intra and supra-sellar mass with mass effect on the optic chiasm and 75% encasement of the left supra-clinoid internal carotid artery. Neurosurgery performed an endoscopic, endonasal partial resection of the pituitary tumor. The histology was diagnostic of an adenoma, and immunohistochemical staining was positive for GH and PRL, but not ACTH. Post-op lab results: GH 1.07 ng/ml, IGF-1 353 ng/ml, PRL 9.6 ng/ml, testosterone 41 ng/dL, ACTH 68.2 pg/ml, cortisol 4.5 ug/dL, 24-hr urine free cortisol 8 mcg, HbA1c 5.7%. Discussion The intent of this case presentation is to report the rare finding of a pituitary tumor co-secreting GH, ACTH, and Prolactin. The diagnosis of acromegaly was confirmed by significant elevations of GH and IGF-1. The diagnosis of subclinical Cushing's disease was confirmed by elevated ACTH level, 24-hr urine free cortisol, and failed dexamethasone suppression test. The elevated PRL may have been due to tumor PRL secretion or stalk effect. The reduction of these parameters after surgery corroborated the presence of pleurihormonal secretion. This patient's findings support screening for co-secretion of multiple pituitary hormones in patients with acromegaly. Reference Pleurihormonal ACTH-GH Adenoma: Case Report and Systematic Literature Review World Neurosurg 2018 114: 158-164 Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Virtual Radiology Fellowship Recruitment: Benefits, Limitations, and Future Directions

Virtual Radiology Fellowship Recruitment: Benefits, Limitations, and Future Directions

M1, M2: Time to Bid Adieu!

M1, M2: Time to Bid Adieu!

Disparities in neurosurgical care for traumatic brain injury

Traumatic brain injury (TBI) is a major public-health problem affecting over 27 million individuals worldwide annually. 1 James SL Theadom A Ellenbogen RG et al. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019; 18: 56-87 Summary Full Text Full Text PDF PubMed Scopus (504) Google Scholar Although most of these injuries are mild, patients with moderate or severe injuries can have a high risk of morbidity and mortality. Some patients require emergency neurosurgical procedures, yet there are substantial gaps in access to neurosurgical care, 2 Corley J Lepard J Barthélemy E Ashby JL Park KB Essential neurosurgical workforce needed to address neurotrauma in low- and middle-income countries. World Neurosurg. 2019; 123: 295-299 Crossref PubMed Scopus (29) Google Scholar , 3 Maas AIR Menon DK Adelson PD et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017; 16: 987-1048 Summary Full Text Full Text PDF PubMed Scopus (867) Google Scholar which are particularly acute in low-income and middle-income countries (LMICs). 3 Maas AIR Menon DK Adelson PD et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017; 16: 987-1048 Summary Full Text Full Text PDF PubMed Scopus (867) Google Scholar However, our understanding of these deficiencies—and, thus, our ability to address them—has been hampered by the lack of high quality epidemiological data. Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort studyPatients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices. Full-Text PDF

IOTG-03. Rapid intraoperative flow cytometry of brain tumor useful for surgical decision-making

Abstract Flow cytometry is a measuring device frequently used in basic research, we have developed a fully automatic flow cytometer device that performs cell isolation, staining of cell nuclei, and measurement for intraoperative diagnosis. Placing a small specimen in a reagent containing PI calculates, the total number of cells, the DNA histogram, and the Malignancy Index (MI), which means in the proliferation phase, the ratio of the number of cells (S, G2, M) / total number of cells. The major feature of this device is that calculating takes only 10 minutes by thoroughly reviewing the process. We here introduce our study of this device, rapid diagnosis, WHO grading, prognosis in glioma, and differentiation from malignant lymphoma (PCNSL), then how to use it in decision making in the operation. In the analysis of 323 gliomas, the threshold between the peripheral brain and the tumor was 7%, and the MI value was correlated with WHO grade (II 13%, III 35%, IV 47%) (J Neurosurg 2013). A correlation was also found between the MI value and the number of residual tumors (Brain Tumor Path 2018). Furthermore, it was also useful for differentiating from PCNSL with many S-phase cells (World Neurosurg 2018). In addition, the relationship between the presence of DNA aneuploidy and poor prognosis in 102 grade II patients (Clin Neuro Neurosurg 2018), and the high MI in 102 grade IV patients showed a good prognosis and an inverse correlation with expectations (Neurosurg 2018). Intraoperative flow cytometry has enabled various intraoperative decision-making support by converting intraoperative histology, which was an analog-like transmission, into digitized histological information. In the future, the development of this research makes expectations for more accurate diagnosis and prediction by artificial intelligence and the development of other departments.

Extended-Reality Technologies: An Overview of Emerging Applications in Medical Education and Clinical Care.

Extended-Reality Technologies: An Overview of Emerging Applications in Medical Education and Clinical Care.

GCT-38. RELAPSE PATTERNS OF INTRACRANIAL GERMINOMAS BEFORE AND AFTER ENDOSCOPIC ERA

PURPOSEWe evaluated the relapse patterns of CNS germinomas before and after introducing neuroendoscopic biopsy in 2000.METHODSWe retrospectively assessed the relapse patterns of 57 patients treated as pure germinoma or germinoma with STGC between 1980 and 2019 at University of Tsukuba, partially containing the patients of the previous report (Takano S et al., World Neurosurg, 2015). Median age was 15 y.o.(7y.o.~38y.o.), and men was 80.7%. Tumor locations were pineal 35, sellar 19, basal ganglia 3, others 11. Group A;1980~1999 was 20, and group B;2000~2019 was 37. From 1980 to 1994, whole brain irradiation(WB) 30.6 Gy plus whole ventricle irradiation(WV) 19.8 Gy. From 1995 to 1999, WV 26~30.6 Gy with Chemotherapy(Chem) or Chem alone. Since 2000, Chem for 3 kurr with WV 24~30.6 Gy, and 6–19.8 Gy as local boost to residual lesion.RESULTSFollow up periods were median 121 M(4.5M~386M; group A), and median 89 M(4 M~231 M; group B). Six patients(30%) recurred in the group A, as ex field 4(1;brain and extramedullary, 1;brain and paranasal sinus, 1;LV & third ventricle, 1;extramedullary), in field 1(LV). Chem only 1(LV & third ventricle). Two patients(5.4%) recurred in the group B, as ex field 2(1;intramedullary, 1;extramedullary). The group A showed CR;18, PR;1, Dead;1(Dissemination), and the group B showed CR;35, PR;1 Dead;1(Encephalopathy).CONCLUSIONWV and Chem prevented extrafield recurrence keeping good quality of life. Neuroendscopy biopsy with ETV did not increase CSF seeding.

AN UNUSUAL SUSPECT: A CASE OF DELAYED CEREBRAL INFARCTS FROM VASOSPASM AFTER A RUPTURED ATERIOVENOUS MALFORMATION

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Subarachnoid hemorrhages (SAH) affect roughly 1 in 10,000 adults annually, with roughly 50% resulting in death soon after development. The majority of the cases are the result of an aneurysm rupture but rarely, can be caused by arteriovenous malformations (AVM’s). The leading cause of morbidity after surviving an SAH is the neurologic deterioration that occurs from delayed cerebral ischemia (DCI) and infarction as a result of vasospasm. AVM’s have only recently been gaining recognition as a cause of clinical deterioration from DCI’s. CASE PRESENTATION: Patient is a 41 yo female with no past medical history who initially presented with complaints of the worst headache of her life. Imaging revealed intraventricular hemorrhage (IVH) with subarachnoid hemorrhage, attributed to a ruptured AVM. CT angiogram showed a left parietal occipital AVM with associated intra-nidal aneurysms. Patient underwent embolization of the AVM and nidal aneurysms. Due to the morphology of the AVM, patient underwent a debulking and resection of the AVM with evacuation of the left IVH. Post-operative course was complicated by acute neurological change (unresponsive, minimal extremity motor exam). Imaging showed new changes consistent with an acute infarct and bilateral narrowing of the anterior and middle cerebral arteries, secondary to vasospasm. She subsequently required multiple intra-arterial treatments with verapamil. Her neurological exam slightly improved with treatments and was subsequently discharged to a long-term acute care facility for therapy. DISCUSSION: Unlike aneurysm rupture, cerebral vasospasm after a ruptured AVM is rarely reported and often not recognized as a cause of delayed cerebral ischemia. This could lead to clinical decline and should be considered in the differentials of neurological deterioration following the hemorrhage of an AVM. A recent retrospective analysis revealed that the SAH component and infratentorial location of a rupture AVM may have a higher risk for cerebral vasospasms and recommended follow-up angiographic imaging in patients with neurological deterioration. However, there currently is no recommendation for empiric delayed angiography to assess for vasospasms after a ruptured AVM. CONCLUSIONS: Despite the robust evidence-based guidelines on the comprehensive management of SAH from aneurysm ruptures, including the management of cerebral vasospasm and DCI, there is no such guideline for ruptured AVM’s. In the setting of acute neurological deterioration after treatment of an AVM (via resection or embolization), assessment for cerebral vasospasm and DCI should be considered. Reference #1: Goss BA, Du R. Vasospasm after arteriovenous malformation rupture. World Neurosurg. ;Sep-Oct;78(3-4):300-5. doi: 10.1016/j.wneu.2011.12.090. Epub 2011 Dec 28. Reference #2: Dinc N, Won Sy, Eibach M. et al. Cerebral vasospasm due to arteriovenous malformation-associated hemorrhage: Impact of bleeding source and pattern. Cerebrovasc Dis. 2019; 47(3-4):165-170. doi: 10.1159/000500596. Reference #3: Pluta RM, Hansen-Schwartz J, Dreier J, et al. Cerebral vasospasm following subarachnoid hemorrhage: time for a new world of thought. Neurol Res. 2009;31(2):151–158. doi:10.1179/174313209X393564 DISCLOSURES: No relevant relationships by Hammad Arshad, source=Web Response Scientific Medical Advisor relationship with ischemaview Please note: $1-$1000 Added 05/01/2020 by Russell cerejo, source=Web Response, value=Travel No relevant relationships by Nathan Esplin, source=Web Response No relevant relationships by Chen Xu, source=Web Response No relevant relationships by Meilin Young, source=Web Response No relevant relationships by Alexander Yu, source=Web Response

ANGIOSARCOMAS: A TALE OF THE RIGHT ATRIAL RARITY

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary cardiac tumors are quite rare with reported incidence rates of 0.001-0.3%. Angiosarcomas most commonly occur in the head and neck, but also account for the majority of malignant primary cardiac tumors. Presenting symptoms are nonspecific and disease is often advanced at time of diagnosis, making early identification crucial. CASE PRESENTATION: A 65 year-old male with a history of CAD and tobacco use was transferred from an outside hospital with fevers, chest pain, hemoptysis, and respiratory distress. He had been admitted twice in the past two months for dyspnea, chest pain, and fatigue. Prior evaluation included a cardiac echo, which showed a large pericardial effusion. Pericardiocentesis was completed twice, but was non-diagnostic with negative fluid studies. Lung nodules were noted on CT, but thought to be benign and pulmonology had recommended outpatient follow-up. He was thus treated with ibuprofen and colchicine and discharged. On this admission, CXR and CT angiography again showed nodular lung infiltrates and a moderate pericardial effusion, but a new heterogeneous 5.1 x 6.0 x 5.0 cm right atrial mass was also noted. A normocytic anemia (Hgb=8.8) and thrombocytosis (platelets=490) were present with a WBC count of 6.69. Repeat echo showed a large hypoechoic lesion next to the right atrium without effusion. Cardiac MRI demonstrated a 9 cm lobulated lesion along the anterior border of the right atrium, suspicious for a mycotic pseudoaneurysm. The lesion was inseparable from the right coronary artery and two globular thrombi were visualized within the lesion. Pericardial thickening suspicious for loculation/abscess and innumerable pulmonary opacities suspicious for septic emboli were noted. Cardiothoracic surgery was consulted, but preoperative left heart catheterization showed neovascularization of the right atrial mass concerning for cardiac angiosarcoma. Given the high risk of endomyocardial biopsy, biopsy of a lung lesion was completed and confirmed metastatic cardiac angiosarcoma. Treatment and prognosis were reviewed, and the patient elected hospice care. DISCUSSION: Primary cardiac tumors present with non-specific symptoms, including chest pain, shortness of breath, and malaise. TEE is the test of choice with a sensitivity of 97% although CTA or MRI may be necessary. 90% of tumors arise in the right atrium with the most common site of metastasis being the lungs. Treatment is not standardized given the low incidence and lack of randomized trials. Wide resection is the main treatment modality, as primary tumors are generally resistant to chemotherapy and radiation, but surgery with adjuvant therapy is still considered. Despite therapy, outcomes are poor with a median survival of 6 months. CONCLUSIONS: Recognizing a primary cardiac tumor may be difficult as presenting symptoms are non-specific. Echo is the diagnostic modality of choice with the primary treatment being resection. Reference #1: Metastatic Cardiac Angiosarcoma to the Lung, Spine, and Brain: A Case Report and Review of the Literature. Lin CT, Ducis K, Tucker S, Tranmer B. World Neurosurg. 2017 Nov;107:1049.e9-1049.e12. doi: 10.1016/j.wneu.2017.08.023. Epub 2017 Aug 9. Review. PMID: 28803168 Reference #2: Echocardiographic Features of Cardiac Angiosarcomas: The Mayo Clinic Experience (1976-2013). Kupsky DF, Newman DB, Kumar G, Maleszewski JJ, Edwards WD, Klarich KW. Echocardiography. 2016 Feb;33(2):186-92. doi: 10.1111/echo.13060. Epub 2015 Oct 13. PMID: 26460068 Reference #3: Primary malignant tumors of the heart: Outcomes of the surgical treatment. Pacini D, Careddu L, Pantaleo A, Parolari A, Leone O, Daprati A, Gargiulo GD, Di Bartolomeo R. Asian Cardiovasc Thorac Ann. 2015 Jul;23(6):645-51. doi: 10.1177/0218492315573674. Epub 2015 Feb 18. PMID: 25698795 DISCLOSURES: No relevant relationships by Courtney Certain, source=Web Response No relevant relationships by Kim Jordan, source=Web Response No relevant relationships by Craig Sewell, source=Web Response No relevant relationships by Shenali Wickramanayake, source=Web Response

How accurate is the neurosurgery literature? A review of references.

The reference list is an important part of academic manuscripts. The goal of this study is to evaluate the reference accuracy in the field of neurosurgery. This study examines four major peer-reviewed neurosurgery journals, chosen based on their clinical impact factor: Neurosurgery, J Neurosurg, World Neurosurg, and Acta Neurochir. For each of the four journals, five articles from each of the journal's 12 issues published in 2019 were randomly selected using an online generator. This resulted in a total of 240 articles, 60 from each journal. Additionally, from each article's list of references, one reference was again randomly selected and checked for a citation or quotation error. The chi-square test was used to analyze the association between the occurrence of citation and quotation errors and the presence of hypothesized risk factors that could impact reference accuracy. 62.1% of articles had a minor citation error, 8.33% had a major citation error, 12.1% had a minor quotation error, and 5.8% of articles had a major quotation error. Overall, Acta Neurochir presented with the fewest quotation errors compared with the other journals evaluated. The only association between the frequency of errors and potential markers of reference mistakes was with the length of the bibliography. Surprisingly, this correlation indicated that the articles with longer reference lists had fewer citation errors (p < 0.01). Statistical significance was found between the occurrence of citation errors and the journals of publication (p < 0.01). In order to advance medical treatment and patient care in neurosurgery, detailed documentation and attention to detail are necessary. The results from this analysis illustrate that improved reference accuracy is required.

Supraorbital keyhole approach for suprasellar arachnoid cyst: how I do it.

Keyhole approaches have lately sparked strong interest because these approaches address skull base pathologies as reported by Eroglu et al. (World Neurosurg, 2019); Hickmann, Gaida, and Reisch (Acta Neurochir (Wien) 159:881-887, 2017); Jallo and Bognar (Neurosurgery, 2006); and Poblete et al. (J Neurosurg 122:1274-1282, 2015), minimizing brain retraction and improving cosmetic results. We describe the step-by-step surgical technique to drain a suprasellar arachnoid cyst by a supraorbital approach. The eyebrow incision is a direct route to expose the supraorbital corridor and even if it is smaller than a pterional approach, it permits to open the cisterns and to visualize neurovascular structures. The arachnoid cyst could be safely drained and a T-tube is placed. This technique represents a suitable option for suprasellar arachnoid cyst, avoiding more extended and invasive approaches.

Microsurgical clipping of an unruptured superiorly projecting ACoM aneurysm in a rotated ACoM complex.

Key Clinical MessageThis case illustrates surgical technique for wide neck aneurysm clipping in a rotated complex and how to manage intraoperative aneurysm rupture while maintaining hemostasis (Cai et al., Anterior communicating artery aneurysm morphology and the risk of rupture. World Neurosurg. 2018;109:119 and Dehdashti et al., The implication of anterior communicating complex rotation and 3‐dimensional computerized tomography angiography findings in surgical approach to anterior communicating artery aneurysms. World Neurosurg. 2016;91:34).