Publications by authors named "Bernard R Bendok"

338 Publications

Endoscopic Endonasal & Transmaxillary Resection of a Nasopharyngeal Angiofibroma.

World Neurosurg 2021 Aug 24. Epub 2021 Aug 24.

Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic in Arizona, Phoenix, AZ; Department of Neurosurgery, Mayo Clinic in Arizona, Phoenix, AZ. Electronic address:

Juvenile nasopharyngeal angiofibromas (JNAs) are highly vascularized, benign lesions that mainly arise in adolescent males. Current treatment options include observation, radiotherapy, or surgical resection. Surgical excision is the treatment of choice as it achieves immediate and complete results, thereby minimizing the risk of recurrence. Here we have reported on a transnasal-transmaxillary endoscopic approach for resection of a JNA in a 16-year-old male patient. The patient presented with one year of progressive nasal obstruction and intermittent episodes of right sided epistaxis. Due to the highly vascular nature of the tumor, embolization of the internal maxillary artery and branches was performed one day prior to surgery. Via endoscope, the right nasal cavity was entered and the nasopharyngeal extension of the tumor was ablated and resected. A maxillary antrostomy and sphenoidectomy was performed to enlarge the maxillary sinus opening. The pterygopalatine fossa was dissected and the tumor was circumferentially freed from the masticator space laterally, the orbit and skull base superiorly, and the basisphenoid posteriorly. The pterygoid plates and basisphenoid plates were drilled down to ablate residual tumor. The patient tolerated the procedure well and post-operative MRI confirmed gross total resection. The sinus cavity was widely patent and no tumor resection was noted 5 months post-operatively. JNAs can be challenging to treat as they can invade extensively into local structures. A careful consideration of treatment options and approaches are necessary when faced with these lesions. No identifiable patient information was included in this manuscript and the patient consented to this procedure.
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http://dx.doi.org/10.1016/j.wneu.2021.08.064DOI Listing
August 2021

Intracranial Aneurysms in Patients with Marfan Syndrome: A Multicenter Propensity-Matched Analysis.

World Neurosurg 2021 Aug 21. Epub 2021 Aug 21.

Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA. Electronic address:

Objective: We sought to identify risk factors for intracranial aneurysms (IAs) in Marfan syndrome (MFS) patients and to describe their characteristics.

Methods: Patients with confirmed MFS and vessel-dedicated brain imaging from January 1, 1980-December 1, 2020 were categorized according to the presence (IA) or absence (NIA) of IAs. Unmatched logistic regression analysis and propensity score matching were used for comparison.

Results: We included 159 patients, of whom 18 (11.3%) patients had radiographic diagnosis of IAs. Three patients (16.7%) had multiple lesions for a total of 24 IAs. One patient (5.5%) had de novo IA formation. Four patients (22.2%) underwent treatment: Two (11.1%) had open surgical clipping for ruptured aneurysms, and two (11.1%) patients had endovascular embolization for growth. In the unmatched analysis, current tobacco smoker status (odds ratio [OR]: 4.20; confidence interval [CI]: 1.11-15.6; P = 0.027) and history of coronary artery disease (CAD) (OR: 5.79; CI 1.76-20.2; P = 0.004) increased the odds for IA. Propensity score matching yielded 18 IA and 18 NIA patients matched for age, gender, race, prior stroke, and family history of aneurysms. History of CAD (IA = 11 [61.1%] vs. NIA = 4 (22.2%), P = 0.043) and current smoker status (IA = 6 [33.3%] vs. NIA = 0 (0%), P < 0.01) were significantly higher in the IA cohort. Body mass index (P = 0.622), diabetes (P = 0.180), hypertension (P = 0.732), prior stroke (P = 1.00), family history (P = 0.732), alcohol (P = 0.314), recreational drugs (P = 1.00), and other aneurysms (P = 0.585) were not statistically significant.

Conclusions: Prevalence of IAs in our series of MFS patients was 11.3%, and de novo formation was 5.5%. MFS patients with a history of CAD and current smoker status had an increased risk of IA. Neurovascular radiographic screening should be considered in all patients with MFS, particularly in patients who smoke or have a history of heart disease.
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http://dx.doi.org/10.1016/j.wneu.2021.08.065DOI Listing
August 2021

Burnout and Emotional Intelligence in Neurosurgical Advanced Practice Providers Across the United States: A Cross-Sectional Analysis.

World Neurosurg 2021 Aug 21. Epub 2021 Aug 21.

Department of Neurosurgery, Mayo Clinic Hospital, Phoenix, Arizona, USA.

Objective: Although much research has examined nursing and physician burnout, the advanced practice provider (APP) population has not yet been studied. The goal of the present study was to survey APPs in neurosurgery to determine whether greater emotional intelligence (EI) is protective against burnout.

Methods: An 80-item survey was created that incorporated the Maslach Burnout Inventory Human Services Survey for Medical Personnel, the Trait Emotional Intelligence Questionnaire-short form, and original questions developed by us. The collective survey was distributed, administered, and collected using the web-based REDCap (Research Electronic Data Capture) platform. Statistical analyses were completed using a comparison between participants with and without burnout.

Results: A total of 106 neurosurgical APPs (26 men, 80 women) completed the survey, of whom, 57 (54%) reported current burnout. High average scores for personal accomplishment and global EI were inversely related to burnout (P = 0.034 and P = 0.003, respectively). In addition, the following factors were associated with burnout: inadequate support staff in the work place (P = 0.008), inadequate time off work (P < 0.001), inadequate administrative time (P = 0.009), not experiencing support from one's supervisor (P = 0.017), insufficient time for continuing medical education (P < 0.001), an inability to separate work from personal time (P < 0.001), and an inability to advance within one's professional field (P = 0.043).

Conclusions: For neurosurgical APPs, EI is protective against burnout. Many opportunities exist at the individual and organizational level to alleviate burnout among neurosurgical APPs. Targeted strategies to improve work-life balance, EI, support systems, and opportunities for career development among neurosurgical APPs might enhance employment satisfaction and reduce burnout.
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http://dx.doi.org/10.1016/j.wneu.2021.08.066DOI Listing
August 2021

A multicenter analysis of the prognostic value of histone H3 K27M mutation in adult high-grade spinal glioma.

J Neurosurg Spine 2021 Aug 20:1-10. Epub 2021 Aug 20.

1Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida.

Objective: High-grade spinal glioma (HGSG) is a rare but aggressive tumor that occurs in both adults and children. Histone H3 K27M mutation correlates with poor prognosis in children with diffuse midline glioma. However, the role of H3 K27M mutation in the prognosis of adults with HGSG remains unclear owing to the rarity of this mutation, conflicting reports, and the absence of multicenter studies on this topic.

Methods: The authors studied a cohort of 30 adult patients with diffuse HGSG who underwent histological confirmation of diagnosis, surgical intervention, and treatment between January 2000 and July 2020 at six tertiary academic centers. The primary outcome was the effect of H3 K27M mutation status on progression-free survival (PFS) and overall survival (OS).

Results: Thirty patients (18 males and 12 females) with a median (range) age of 50.5 (19-76) years were included in the analysis. Eighteen patients had H3 K27M mutation-positive tumors, and 12 had H3 K27M mutation-negative tumors. The median (interquartile range) PFS was 3 (10) months, and the median (interquartile range) OS was 9 (23) months. The factors associated with increased survival were treatment with concurrent chemotherapy/radiation (p = 0.006 for PFS, and p ≤ 0.001 for OS) and American Spinal Injury Association grade C or better at presentation (p = 0.043 for PFS, and p < 0.001 for OS). There were no significant differences in outcomes based on tumor location, extent of resection, sex, or H3 K27M mutation status. Analysis restricted to HGSG containing necrosis and/or microvascular proliferation (WHO grade IV histological features) revealed increased OS for patients with H3 K27M mutation-positive tumors (p = 0.017).

Conclusions: Although H3 K27M mutant-positive HGSG was associated with poor outcomes in adult patients, the outcomes of patients with H3 K27M mutant-positive HGSG were somewhat more favorable compared with those of their H3 K27M mutant-negative HGSG counterparts. Further preclinical animal studies and larger clinical studies are needed to further understand the age-dependent effects of H3 K27M mutation.
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http://dx.doi.org/10.3171/2021.2.SPINE201675DOI Listing
August 2021

Microsurgical Resection of Dorsal Pontine Cavernous Malformation: The Telovelar Approach Augmented by the Tonsillouvular Fissure Exposure: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Sep;21(4):E373-E374

Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA.

Surgical approaches to lesions of the fourth ventricle (FV) have been modified over the years to reduce the complications associated with splitting the inferior cerebellar vermis (ICV) and disrupting the brainstem and critical surrounding structures.1-4 Two common approaches to lesions of this region include the transvermian approach (TVA) and telovelar approach (TeVA).2 The TVA was initially considered the conventional route of access to lesions of the FV1 but has been associated with significant risks, including possible gait ataxia and dysarthria.3 The TeVA is advantageous, as it involves dissection along natural clefts and division of non-neural tissue and provides good exposure of the superolateral recess with modest exposure of the rostral FV. The TeVA approach can be augmented by opening the tonsilouvular fissures (TUFs). This added dissection allows greater lateral and superior exposure with less need for retraction. In this operative video, we demonstrate a case in which we augmented the TeVA with a TUF dissection to access a dorsal pontine cavernous malformation. We performed a midline suboccipital craniotomy with a C1 posterior laminectomy. TUF dissection was followed by division of the tela choroidea (TC), which allowed for more lateral exposure of the FV and excellent visualization of the cavernous malformation without the need to traverse neural tissue. TeVA augmented by TUF dissection provided adequate access to the dorsal pons for complete resection of the cavernous malformation. The patient consented to the procedure as shown in this operative video and gave informed written consent for use of her images in publication. Anatomic images provided by courtesy of © The Rhoton Collection. http://rhoton.ineurodb.org/. Video © Mayo Foundation for Medical Education and Research, 2021. Used with permission.
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http://dx.doi.org/10.1093/ons/opab264DOI Listing
September 2021

Awake Resection of an Arteriovenous Malformation.

World Neurosurg 2021 Jul 7. Epub 2021 Jul 7.

Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ; Department of Otolaryngology, Mayo Clinic, Phoenix, AZ; Department of Radiology, Mayo Clinic, Phoenix, AZ; Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, AZ; Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, AZ. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2021.06.146DOI Listing
July 2021

Microvascular Decompression Technique for Trigeminal Neuralgia Using a Vascular Clip.

World Neurosurg 2021 Jul 6;154. Epub 2021 Jul 6.

Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA; Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, USA; Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona. Electronic address:

Microvascular decompression (MVD) surgery is a well-established, effective treatment option for trigeminal neuralgia and hemifacial spasm. In 1967, Janetta et al introduced the concept of MVD surgery and pioneered the Janetta technique in which Teflon felt implants are placed between the trigeminal nerve and offending vessel. Though many cases are successfully managed with Teflon interposition, alternative techniques have been developed with the objective to alleviate vascular compression symptoms indefinitely, including transposition using biological glue, vascular clips, and a variety of "sling" techniques. In Video 1, we demonstrate a fenestrated clip transposition technique in the treatment of trigeminal neuralgia. We present the case of a 72-year-old female who presented with classic trigeminal neuralgia pain along the V2 and V3 distributions. Magnetic resonance imaging revealed evident compression of the trigeminal nerve by the superior cerebellar artery (SCA). A retrosigmoid craniotomy was performed, and the vascular loop of the SCA was visualized compressing the root entry zone with significant indentation of the trigeminal nerve. Wide arachnoid dissection along the SCA was carried out in order to mobilize the SCA away from the nerve. A small slit was created in the undersurface of the tentorium, and then the SCA loop was transposed to the tentorium using a fenestrated aneurysm clip. The postoperative course was uneventful, and the patient had complete resolution of her facial pain at 6-month follow-up. This method is likely an effective and durable method of decompression for trigeminal neuralgia.
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http://dx.doi.org/10.1016/j.wneu.2021.06.124DOI Listing
July 2021

Outcomes and Surgical Considerations for Neurosurgical Patients Hospitalized with COVID-19-A Multicenter Case Series.

World Neurosurg 2021 Jul 6. Epub 2021 Jul 6.

Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida. Electronic address:

Objective: Neurosurgical patients are at a higher risk of having a severe course of coronavirus disease 2019 (COVID-19). The objective of this study was to determine morbidity, hospital course, and mortality of neurosurgical patients during the coronavirus disease 2019 (COVID-19) pandemic in a multicenter health care system.

Methods: A retrospective observational study was conducted to identify all hospitalized neurosurgical patients positive for COVID-19 from March 11, 2020 to November 2, 2020 at Mayo Clinic and the Mayo Clinic Health System.

Results: Eleven hospitalized neurosurgical patients (0.68%) were positive for COVID-19. Four patients (36.6%) were men and 7 (63.3%) were women. The mean age was 65.7 years (range, 35-81 years). All patients had comorbidities. The mean length of stay was 13.4 days (range, 4-30 days). Seven patients had a central nervous system malignancy (4 metastases, 1 meningioma, 1 glioblastoma, and 1 schwannoma). Three patients presented with cerebrovascular complications, comprising 2 spontaneous intraparenchymal hemorrhages and 1 ischemic large-vessel stroke. One patient presented with an unstable traumatic spinal burst fracture. Four patients underwent neurosurgical/neuroendovascular interventions. Discharge disposition was to home in 5 patients, rehabilitation facility in 3, and hospice in 3. Five patients had died at follow-up, 3 within 30 days from COVID-19 complications and 2 from progression of their metastatic cancer.

Conclusions: COVID-19 is rare among the inpatient neurosurgical population. In all cases, patients had multiple comorbidities. All symptomatic patients from the respiratory standpoint had complications during their hospitalization. Deaths of 3 patients who died within 30 days of hospitalization were all related to COVID-19 complications. Neurosurgical procedures were performed only if deemed emergent.
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http://dx.doi.org/10.1016/j.wneu.2021.06.147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8257398PMC
July 2021

Commentary: Medial Acoustic Tumors: Special Considerations: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Aug;21(3):E291-E292

Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic in Arizona, Phoenix, Arizona, USA.

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http://dx.doi.org/10.1093/ons/opab189DOI Listing
August 2021

Influence of supramarginal resection on survival outcomes after gross-total resection of IDH-wild-type glioblastoma.

J Neurosurg 2021 Jun 4:1-8. Epub 2021 Jun 4.

Departments of1Neurosurgery.

Objective: The authors' goal was to use a multicenter, observational cohort study to determine whether supramarginal resection (SMR) of FLAIR-hyperintense tumor beyond the contrast-enhanced (CE) area influences the overall survival (OS) of patients with isocitrate dehydrogenase-wild-type (IDH-wt) glioblastoma after gross-total resection (GTR).

Methods: The medical records of 888 patients aged ≥ 18 years who underwent resection of GBM between January 2011 and December 2017 were reviewed. Volumetric measurements of the CE tumor and surrounding FLAIR-hyperintense tumor were performed, clinical variables were obtained, and associations with OS were analyzed.

Results: In total, 101 patients with newly diagnosed IDH-wt GBM who underwent GTR of the CE tumor met the inclusion criteria. In multivariate analysis, age ≥ 65 years (HR 1.97; 95% CI 1.01-2.56; p < 0.001) and contact with the lateral ventricles (HR 1.59; 95% CI 1.13-1.78; p = 0.025) were associated with shorter OS, but preoperative Karnofsky Performance Status ≥ 70 (HR 0.47; 95% CI 0.27-0.89; p = 0.006), MGMT promotor methylation (HR 0.63; 95% CI 0.52-0.99; p = 0.044), and increased percentage of SMR (HR 0.99; 95% CI 0.98-0.99; p = 0.02) were associated with longer OS. Finally, 20% SMR was the minimum percentage associated with beneficial OS (HR 0.56; 95% CI 0.35-0.89; p = 0.01), but > 60% SMR had no significant influence (HR 0.74; 95% CI 0.45-1.21; p = 0.234).

Conclusions: SMR is associated with improved OS in patients with IDH-wt GBM who undergo GTR of CE tumor. At least 20% SMR of the CE tumor was associated with beneficial OS, but greater than 60% SMR had no significant influence on OS.
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http://dx.doi.org/10.3171/2020.10.JNS203366DOI Listing
June 2021

Microsurgical Clipping of a Post-Coiling, Residual or Recurrent, Ruptured Anterior Communicating Artery Aneurysm.

World Neurosurg 2021 May 13. Epub 2021 May 13.

Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ; Department of Otolaryngology, Mayo Clinic, Phoenix, AZ; Department of Radiology, Mayo Clinic, Phoenix, AZ; Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, AZ; Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, AZ. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2021.05.010DOI Listing
May 2021

Commentary: Pineal Region Hemangioblastoma Resection Through Paramedian Supracerebellar Approach: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 06;21(1):E36-E37

Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA.

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http://dx.doi.org/10.1093/ons/opab127DOI Listing
June 2021

Optic Canal Decompression: Concepts and Techniques: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Aug;21(3):E255-E256

Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA.

The optic canal (OC) is a bony channel that transmits the optic nerve (ON) and ophthalmic artery (OphA) as they course through the lesser wing of the sphenoid bone to the orbital apex. The OC is involved in a variety of intracranial and extracranial pathologies,1 and opening of the canal may be necessary in order to achieve adequate exposure, better disease control, and vision preservation.2 Depending on the location of the pathology and its relationship with the optic nerve, the OC may be decompressed through an open transcranial approach or an endoscopic endonasal approach.1,3 OC drilling can be tailored based on the location of the pathology and its extension. Anterior clinoid process and optic strut drilling can be added based on these factors as well.4,5 In this video, we demonstrate the steps of OC drilling in both transcranial microscopic and endoscopic endonasal approaches through a combination of animated illustrations and operative videos. We present 4 cases, including 2 transcranial microscopic and 2 endoscopic endonasal approaches,6 demonstrating OC decompression and its technical nuances. Each case was selected to represent the range of pathologies relevant to OC drilling to allow for a complete understanding of the techniques and concepts required for optimal treatment. An informed written consent has been obtained from each of the patients in this publication. Video © Mayo Foundation for Medical Education and Research. All rights reserved. Images at 1:03-1:10 © The Rhoton Collection. Images at 3:56-4:07 Reprinted from World Neurosurgery, vol 124, Caporlingua et al,3 Copyright 2019, with permission from Elsevier. Images at 9:02-9:48 reprinted from Bendok et al,6 by permission of the Congress of Neurological Surgeons.
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http://dx.doi.org/10.1093/ons/opab117DOI Listing
August 2021

Coma recovery scale: Key clinical tool ignored enough in disorders of consciousness.

Surg Neurol Int 2021 8;12:93. Epub 2021 Mar 8.

Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA.

Background: Disorders of consciousness (DoC) includes coma, vegetative state (VS), minimally conscious state (MCS), and emergence from the MCS. Aneurysmal rupture with high-grade SAH, traumatic brain injury, and neoplastic brain lesions are some of the frequent pathologies leading to DoC. The diagnostic errors among these DoC are as high as ranging from 25% to 45%, with a probable error in the conclusion of patients' state, treatment choice, end-of-life decision-making, and prognosis. Some studies also reported that 37-43% of patients were misdiagnosed in VS while demonstrating signs of awareness. Despite its wide acceptance, Coma Recovery Scale-Revised (CRS-r) remained underused or inappropriately utilized, which may lead to substandard or unprofessional patient care. Literature is rare on the knowledge of CRS-r among physicians published from India and across the globe. Therefore, we carried out the present study to ascertain physicians' knowledge on CRS-r and raise awareness about its justifiable clinical utilization. We also explored the factors associated with this perceived level of experience among participants and recommend frequent physicians' training for care of patients with DoC.

Methods: An institution-based cross-sectional online survey was conducted from June 8 to July 7, 2020, among Ninety-six physicians recruited using a convenient sampling technique. Twenty-item, validated, reliable, and a pilot-tested questionnaire was used to assess the knowledge regarding CRS-r and collect socio-demographic variables. The analysis was performed using the Statistical Package for the Social Sciences version 23. Bivariate and multivariate logistic regression analyses were employed to assess the association of participants' socio-demographic variables and their parent department of work with the knowledge. < 0.05 was considered statistically significant in the multivariate analysis.

Results: A total of Ninety-six participants were included in the analysis, and only 33.3% of them were found to have adequate knowledge of CRS-r. Multivariate analysis revealed that age (adjusted odds ratio [AOR] = 31.66; 95% CI: 6.25-160.36), gender (AOR = 44.16; 95% CI: 7.43-268.23), and parent department of working (AOR = 0.148; 95% CI: 0.06-0.39) were significantly associated with the knowledge.

Conclusion: Knowledge of the physicians on CRS-r is found to be exceptionally low. It has a strong tendency to adversely affect patients' optimal care with disorders of consciousness (DoC). Therefore, it is crucial to expand physicians' knowledge and awareness regarding CRS-r to adequately screen patients with DoC.
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http://dx.doi.org/10.25259/SNI_935_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982119PMC
March 2021

Does General Anesthesia Compared With Conscious Sedation Result in Better Outcomes in Acute Stroke Patients Undergoing Endovascular Therapy?

Neurologist 2021 Mar 4;26(2):47-51. Epub 2021 Mar 4.

Mayo Clinic in Arizona, Scottsdale, AZ.

Background: There is considerable controversy surrounding the optimal use of sedation in patients with acute ischemic stroke undergoing mechanical thrombectomy. Several retrospective studies have favored conscious sedation (CS) over general anesthesia (GA) in terms of functional outcomes and mortality. Recent data from randomized controlled trials has challenged this view.

Objective: The aim was to critically assess current evidence regarding the use of CS versus GA in mechanical thrombectomy for acute ischemic stroke.

Methods: The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular neurology, vascular neurosurgery, and interventional neuroradiology.

Results: A randomized controlled trial was selected for critical appraisal. This trial compared 128 patients with acute ischemic stroke and large vessel occlusion from a single center (Aarhus University Hospital, Denmark), 65 of whom received GA and 63 received CS. No significant difference was detected for the primary outcome of volume of infarct growth. The rate of successful thrombectomy and favorable clinical outcomes for the GA arm was significantly higher in the intention-to-treat analysis.

Conclusions: GA does not result in worse tissue outcomes or worse clinical outcomes when compared with CS in acute stroke patients with large vessel occlusion undergoing mechanical thrombectomy.
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http://dx.doi.org/10.1097/NRL.0000000000000318DOI Listing
March 2021

Uncertainty quantification in the radiogenomics modeling of EGFR amplification in glioblastoma.

Sci Rep 2021 Feb 16;11(1):3932. Epub 2021 Feb 16.

Department of Radiology, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA.

Radiogenomics uses machine-learning (ML) to directly connect the morphologic and physiological appearance of tumors on clinical imaging with underlying genomic features. Despite extensive growth in the area of radiogenomics across many cancers, and its potential role in advancing clinical decision making, no published studies have directly addressed uncertainty in these model predictions. We developed a radiogenomics ML model to quantify uncertainty using transductive Gaussian Processes (GP) and a unique dataset of 95 image-localized biopsies with spatially matched MRI from 25 untreated Glioblastoma (GBM) patients. The model generated predictions for regional EGFR amplification status (a common and important target in GBM) to resolve the intratumoral genetic heterogeneity across each individual tumor-a key factor for future personalized therapeutic paradigms. The model used probability distributions for each sample prediction to quantify uncertainty, and used transductive learning to reduce the overall uncertainty. We compared predictive accuracy and uncertainty of the transductive learning GP model against a standard GP model using leave-one-patient-out cross validation. Additionally, we used a separate dataset containing 24 image-localized biopsies from 7 high-grade glioma patients to validate the model. Predictive uncertainty informed the likelihood of achieving an accurate sample prediction. When stratifying predictions based on uncertainty, we observed substantially higher performance in the group cohort (75% accuracy, n = 95) and amongst sample predictions with the lowest uncertainty (83% accuracy, n = 72) compared to predictions with higher uncertainty (48% accuracy, n = 23), due largely to data interpolation (rather than extrapolation). On the separate validation set, our model achieved 78% accuracy amongst the sample predictions with lowest uncertainty. We present a novel approach to quantify radiogenomics uncertainty to enhance model performance and clinical interpretability. This should help integrate more reliable radiogenomics models for improved medical decision-making.
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http://dx.doi.org/10.1038/s41598-021-83141-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886858PMC
February 2021

Use of Temporary Rod and Intraoperative Neuroimaging for Correction of Adolescent Idiopathic Scoliosis: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 05;20(6):E438

Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA.

Adolescent idiopathic scoliosis (AIS) is an abnormal lateral curvature of the spine that arises during the pubescent growth spurt. AIS mainly affects females in the age group of 10 to 16 yr, with a prevalence of about 1% to 3% in the at-risk population.1 Treatment options vary depending on disease presentation and severity. Mild curvature mainly requires periodic observation for disease progression, whereas more moderate curvature can necessitate bracing or corrective surgery.2 Here, we present the use of a temporary rod and neuroimaging for the correction of Lenke type 1 spinal curvature in an AIS patient. An inferior facetectomy is performed, and a Lenke probe is used for entry into the pedicle and vertebral body. The channel is sounded before and after tapping to check for adequate walls prior to insertion of the pedicle screw. The ARTIS pheno is brought into the field, which uses fluoroscopy to create a 3-dimensional (3D) representation of the instrumentation within the spine. A temporary rod is placed in the concavity, and a combination of corrective techniques, including a rod roll, apical translation, and reduction, is performed to bring up the concavity, derotate the spine, and translate the spine. The permanent rod is then placed in the convexity, and compression is performed to bring down the scapular prominence. The temporary rod is then removed, and a final rod is placed to complete the 3D correction. The patient consented to the procedure, and an informed written consent was obtained from the patient to use her photographs and video recordings for publication.
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http://dx.doi.org/10.1093/ons/opab002DOI Listing
May 2021

Initiation of a Robotic Program in Spinal Surgery: Experience at a Three-Site Medical Center.

Mayo Clin Proc 2021 05 28;96(5):1193-1202. Epub 2020 Dec 28.

Department of Neurologic Surgery, Mayo Clinic, Rochester, MN.

Objective: To highlight the early experience of implementing a robotic spine surgery program at a three-site medical center, evaluating the impact of increasing experience on the operative time and number of procedures performed.

Patients And Methods: A retrospective chart review of patients undergoing robotic screw placement between September 4, 2018, and October 16, 2019, was conducted. Baseline characteristics as well as intraoperative and post-operative outcomes were obtained.

Results: For a total of 77 patients, the mean age (SD) was 55.7 years (11.5) and 49.4% (n=38) were female. A total of 402 screws were placed (384 pedicle screws, 18 cortical screws) using robotic guidance with a median of two operative levels (interquartile range [IQR], 1 to 2). Median (IQR) estimated blood loss was 100 mL (50 to 200 mL) and the median (IQR) operative time was 224 minutes (193 to 307 minutes). With accrual of surgical experience, operative time declined significantly (R=-0.39; P<.001) whereas the number of procedures performed per week increased (R=0.30; P=.05) throughout the study period. Median (IQR) length of hospital stay following surgery was 2 days (IQR, 2 to 3 days). There were two screws requiring revision intraoperatively. No postoperative revisions were required, and no complications were encountered related to screw placement.

Conclusion: Early experience at our institution using a spinal robot has demonstrated no requirement for postoperative screw revisions and no complications related to screw malposition. The increased operative times were reduced as the frequency of procedures increased. Moreover, procedural times diminished over a short period with a weekly increasing number of procedures.
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http://dx.doi.org/10.1016/j.mayocp.2020.07.034DOI Listing
May 2021

Higher Risk for Reintervention in Patients after Stenting for Radiation-Induced Internal Carotid Artery Stenosis: A Single-Center Analysis and Systematic Review.

Ann Vasc Surg 2021 May 26;73:1-14. Epub 2020 Dec 26.

Department of Neurology, Mayo Clinic, Jacksonville, FL.

Background: This study aimed to review short- and long-term outcomes of all carotid artery stenting (CAS) in patients with radiation-induced (RI) internal carotid artery (ICA) stenosis compared with patients with atherosclerotic stenosis (AS).

Methods: We performed a single-center, multisite case-control study of transfemoral carotid artery intervention in patients stented for RI or AS. Cases of stented RI carotid arteries were identified using a CAS database covering January 2000 to December 2019. These patients were randomly matched 2:1 with stented patients because of AS by age, sex, and year of CAS. A conditional logistic regression model was performed to estimate the odds of reintervention in the RI group. Finally, a systematic review was performed to assess the outcomes of RI stenosis treated with CAS.

Results: There were 120 CAS in 113 patients because of RI ICA stenosis. Eighty-nine patients (78.8%) were male, and 68 patients (60.2%) were symptomatic. The reasons for radiation included most commonly treatment for diverse malignancies of the head and neck in 109 patients (96.5%). The mean radiation dose was 58.9 ± 15.6 Gy, and the time from radiation to CAS was 175.3 ± 140.4 months. Symptoms included 31 transient ischemic attacks (TIAs), 21 strokes (7 acute and 14 subacute), and 17 amaurosis fugax. The mean National Institutes of Health Stroke Scale in acute strokes was 8.7 ± 11.2. In asymptomatic patients, the indication for CAS was high-grade stenosis determined by duplex ultrasound. All CAS were successfully completed. Reinterventions were more frequent in the RI ICA stenosis cohort compared with the AS cohort (10.1% vs. 1.4%). Reinterventions occurred in 14 vessels, and causes for reintervention were restenosis in 12 followed by TIA/stroke in two vessels. On conditional regression modeling, patients with RI ICA stenosis were at a higher risk for reintervention (odds ratio = 7.1, 95% confidence interval = 2.1-32.8; P = 0.004). The mean follow-up was 33.7 ± 36.9 months, and the mortality across groups was no different (P = 0.12).

Conclusions: In our single-center, multisite cohort study, patients who underwent CAS for RI ICA stenosis experienced a higher rate of restenosis and a higher number of reinterventions compared with CAS for AS. Although CAS is safe and effective for this RI ICA stenosis cohort, further data are needed to reduce the risk of restenosis, and close patient surveillance is warranted. In our systematic review, CAS was considered an excellent alternative option for the treatment of patients with RI ICA stenosis. However, careful patient selection is warranted because of the increased risk of restenosis on long-term follow-up.
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http://dx.doi.org/10.1016/j.avsg.2020.11.027DOI Listing
May 2021

Seizure outcome in patients with cavernous malformation after early surgery.

Epilepsy Behav 2021 02 15;115:107662. Epub 2020 Dec 15.

Department of Neurology, Northwestern University Feinberg School of Medicine, United States. Electronic address:

Objective: To describe seizure outcome and complications in patients with cavernous malformations (CM) undergoing early versus late surgery.

Methods: A database was created for all CM patients who presented with seizure referred to the neurosurgical clinic at an academic center. A telephone survey and chart review were conducted to evaluate for preoperative and postoperative seizure frequency. Postoperative seizure-free outcome of patients who had ≤2 preoperative seizures versus those that had >2 preoperative seizures was compared.

Results: A total of 35 CM patients were included for analysis. Nineteen patients had ≤2 preoperative seizures and 16 patients had >2 preoperative seizures, six of them drug resistant for over two years. Among the ≤2 seizure group, 15 had only a single seizure before surgical resection. 94.7% of patients with ≤2 preoperative seizures and 62.5% of patients with >2 preoperative seizures were seizure free one year following surgical resection (p = 0.019). 78.9% of patients with ≤2 preoperative seizures and 25% of patients with >2 preoperative seizures were able to wean off AEDs (p < 0.001). Among those patients who had a single preoperative seizure, 100% of patients were seizure free at one year.

Conclusions: Early surgical resection for CM patients who present after a CM-related seizure is an effective, well tolerated treatment and has good chance to offer seizure freedom without the need for long-term antiepileptic medications. Outcome for patients operated with only one or two preoperative seizures may lead to better results than patients who delay the procedure.
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http://dx.doi.org/10.1016/j.yebeh.2020.107662DOI Listing
February 2021

LZTR1-related spinal schwannomatosis and 7q11.23 duplication syndrome: A complex phenotype with dual diagnosis.

Mol Genet Genomic Med 2021 01 2;9(1):e1560. Epub 2020 Dec 2.

Department of Neurology, Mayo Clinic, Phoenix, AZ, USA.

Background: Dual diagnoses in genetics practice are not uncommon and patients with dual diagnosis often present with complex and challenging phenotypes. A combination of meticulous phenotyping and molecular genetic techniques are essential in solving these diagnostic odysseys.

Methods: Clinical features and genetic workup of a patient presenting with incidental schwannomatosis.

Results: A 19-year-old male presented with incidental painless schwannomatosis in the background of macrocephaly, distinctive facies, and learning disability. Comprehensive genetic testing with gene panel and chromosomal microarray led to a dual diagnosis of LZTR1-related schwannomatosis and 7q11.23 duplication syndrome.

Conclusion: We emphasize the need for high index of suspicion and comprehensive genetic testing in complex phenotypes. Interrogation of the interplay between the pathogenic variants in multiple genes could improve our understanding of the pathophysiologic pathways and contribute to therapeutic discoveries.
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http://dx.doi.org/10.1002/mgg3.1560DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7963420PMC
January 2021

Quality of Life of Patients with Unruptured Intracranial Aneurysms Before and After Endovascular Coiling: A HEAT Trial Secondary Study and Systematic Review of the Literature.

World Neurosurg 2021 02 27;146:e492-e500. Epub 2020 Oct 27.

Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA; Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, USA; Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA. Electronic address:

Background: The study of quality of life (QOL) in patients with asymptomatic diseases receiving interventional treatment provides an essential metric for the assessment of procedural benefits in the surgical patient population. In this study, we analyzed QOL data collected from patients with unruptured intracranial aneurysms (UIAs) before and after endovascular coiling in the HEAT Trial, alongside a systematic review on QOL in unruptured brain aneurysms.

Methods: HEAT was a randomized controlled trial comparing recurrence rates in aneurysms treated with either bare platinum coils or hydrogel coils. Patients enrolled in this trial completed a short form-36 (SF-36) QOL questionnaire before treatment and at the 3- to 12- and 18- to 24-month follow-ups. The change in QOL before and after treatment was assessed. Regression analysis evaluated the effect of select baseline characteristics on QOL change.

Results: A total of 270 patients were eligible for analysis. There was an increase in the role physical (P = 0.043), vitality (P = 0.022), and emotional well-being (P < 0.001) QOL components at the 18- to 24-month follow-up compared with baseline scores. Regression analysis showed that age younger than 60 and absence of serious adverse events were associated with improved social functioning and vitality. The literature review showed a mixed effect of intervention on QOL in patients with UIAs.

Conclusions: Our analysis has revealed that patients with 3- to 14-mm UIAs had improvements in some physical and emotional components of QOL at 18-24 months following aneurysm coiling in the HEAT study. The literature remains indeterminate on this issue. Further studies are needed to better understand the effects of the diagnosis of UIAs and their treatment on QOL.
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http://dx.doi.org/10.1016/j.wneu.2020.10.120DOI Listing
February 2021

Linear accelerator-based single-fraction stereotactic body radiotherapy for symptomatic vertebral body hemangiomas: The Mayo Clinic experience.

J Clin Neurosci 2020 Oct 17;80:74-78. Epub 2020 Aug 17.

Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA. Electronic address:

Symptomatic vertebral hemangiomas (SVHs) are rare benign tumors that when symptomatic require procedural intervention or radiotherapy (RT). Although conventionally-fractionated RT has been an alternative to surgical resection, there is very little data on stereotactic body radiotherapy (SBRT) for SVHs. Six consecutively treated patients with SVHs underwent definitive single-fraction SBRT from 2010 to 2018 at our institution. The RT planning parameters, treatment, outcome, and toxicities are reported for 6 patients with 6 total SVHs treated with single-fraction SBRT. Each patient presented with back pain and received single-fraction SBRT to a thoracic vertebral body hemangioma. One patient had received radiofrequency ablation prior to SBRT. The median SBRT dose was 18 Gy (range, 13-20). Following SBRT, 4 (67%) patients reported improvement in presenting symptoms and 2 patients (33%) were refractory. There were no acute or chronic toxicities associated with SBRT including esophagitis, vertebral compression fractures, or myelopathy. To date, this is the largest series of single-fraction SBRT for SVHs. Single fraction SBRT appears to be a feasible option for SVHs. Further studies are needed to confirm our preliminary findings and optimize dose fractionation.
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http://dx.doi.org/10.1016/j.jocn.2020.07.060DOI Listing
October 2020

Prognostic significance of C1-C2 facet malalignment after surgical decompression in adult Chiari malformation type I: a pilot study based on the Chicago Chiari Outcome Scale.

J Neurosurg Spine 2020 10 16:1-7. Epub 2020 Oct 16.

2Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida.

Objective: The authors assessed the prognostic significance of various clinical and radiographic characteristics, including C1-C2 facet malalignment, in terms of surgical outcomes after foramen magnum decompression of adult Chiari malformation type I.

Methods: The electronic medical records of 273 symptomatic patients with Chiari malformation type I who were treated with foramen magnum decompression, C1 laminectomy, and duraplasty at Mayo Clinic were retrospectively reviewed. Preoperative and postoperative Neurological Scoring System scores were compared using the Friedman test. Bivariate analysis was conducted to identify the preoperative variables that correlated with the patient Chicago Chiari Outcome Scale (CCOS) scores. Multiple linear regression analysis was subsequently performed using the variables with p < 0.05 on the bivariate analysis to check for independent associations with the outcome measures. Statistical software SPSS version 25.0 was used for the data analysis. Significance was defined as p < 0.05 for all analyses.

Results: Fifty-two adult patients with preoperative clinical and radiological data and a minimum follow-up of 12 months were included. Motor deficits, syrinx, and C1-C2 facet malalignment were found to have significant negative associations with the CCOS score at the 1- to 3-month follow-up (p < 0.05), while at the 9- to 12-month follow-up only swallowing function and C1-C2 facet malalignment were significantly associated with the CCOS score (p < 0.05). Multivariate analysis showed that syrinx presence and C1-C2 facet malalignment were independently associated with the CCOS score at the 1- to 3-month follow-up. Swallowing function and C1-C2 facet malalignment were found to be independently associated with the CCOS score at the 9- to 12-month follow-up.

Conclusions: The observed results in this pilot study suggest a significant negative correlation between C1-C2 facet malalignment and clinical outcomes evaluated by the CCOS score at 1-3 months and 9-12 months postoperatively. Prospective studies are needed to further validate the prognostic value of C1-C2 facet malalignment and the potential role of atlantoaxial fixation as part of the treatment.
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http://dx.doi.org/10.3171/2020.6.SPINE20544DOI Listing
October 2020

A Rare Intracranial Collision Tumor of Meningioma and Metastatic Uterine Adenocarcinoma: Case Report and Literature Review.

World Neurosurg 2021 01 25;145:340-347. Epub 2020 Sep 25.

Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA. Electronic address:

Background: A collision tumor is a rare entity consisting of 2 histologically distinct tumor types (benign or malignant) in the same anatomic location. This can occur from a tumor-to-tumor metastasis or as a result of 2 adjacent intracranial tumors colliding and growing together. To our knowledge, this is the first reported case of collision tumor with confirmed meningioma and uterine adenocarcinoma. Multiple mechanisms have been proposed for the facilitative growth of collision tumors, including local epigenetic signaling. Clinically, it is important to consider collision tumors in the differential diagnosis of a rapidly growing intracranial lesion in the setting of systemic cancer to provide optimal surgical and postoperative management.

Case Description: A 78-year-old, right-handed woman with a known 10-year history of stable meningioma presented for evaluation of a right sphenoid wing lesion. She had recently completed treatment of uterine papillary serous carcinoma with no evidence of disease on follow-up imaging. On presentation, there was significant progression of the meningioma resulting in brain compression and right third nerve palsy. The patient underwent urgent resection of the lesion. Pathology demonstrated a collision tumor with a combination of metastatic uterine papillary serous carcinoma and meningioma.

Conclusions: It is important to consider a collision tumor when a patient with a benign intracranial lesion presents with rapid progression, even in the context of a systemic cancer that rarely metastasizes to the brain. Appropriate histopathologic assessment is crucial in these cases and can have a significant impact on treatment plan and prognosis.
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http://dx.doi.org/10.1016/j.wneu.2020.09.108DOI Listing
January 2021

Does location matter? Characterisation of the anatomic locations, molecular profiles, and clinical features of gliomas.

Neurol Neurochir Pol 2020 11;54(5):456-465. Epub 2020 Sep 11.

Mayo Clinic Arizona Department of Neurology.

Background: Neuroanatomic locations of gliomas may influence clinical presentations, molecular profiles, and patients' prognoses.

Methods: We investigated our institutional cancer registry to include patients with glioma over a 10-year period. Statistical tests were used to compare demographic, genetic, and clinical characteristics among patients with gliomas in different locations. Survival analysis methods were then used to assess associations between location and overall survival in the full cohort, as well as in relevant subgroups.

Results: 182 gliomas were identified. Of the tumours confined to a single lobe, there were 51 frontal (28.0%), 50 temporal (27.5%), 22 parietal (12.1%), and seven occipital tumours (3.8%) identified. Tumours affecting the temporal lobe were associated with reduced overall survival when compared to all other tumours (11 months vs. 13 months, log-rank p = 0.0068). In subgroup analyses, this result was significant for males [HR (95%CI) 2.05 (1.30, 3.24), p = 0.002], but not for females [HR (95%CI) 1.12 (0.65, 1.93), p = 0.691]. Out of 82 cases tested for IDH-1, 10 were mutated (5.5%). IDH-1 mutation was present in six frontal, two temporal, one thalamic, and one multifocal tumour. Out of 21 cases tested for 1p19q deletions, 12 were co-deleted, nine of which were frontal lobe tumours. MGMT methylation was assessed in 45 cases; 7/14 frontal tumours and 6/13 temporal tumours were methylated.

Conclusion: Our results support the hypothesis that the anatomical locations of gliomas influence patients' clinical courses. Temporal lobe tumours were associated with poorer survival, though this association appeared to be driven by these patients' more aggressive tumour profiles and higher risk baseline demographics. Independently, female patients who had temporal lobe tumours fared better than males. Molecular analysis was limited by the low prevalence of genetic testing in the study sample, highlighting the importance of capturing this information for all gliomas.

Importance Of This Study: The specific neuroanatomic location of tumours in the brain is thought to be predictive of treatment options and overall prognosis. Despite evidence for the clinical significance of this information, there is relatively little information available regarding the incidence and prevalence of tumours in the different anatomical regions of the brain. This study has more fully characterised tumour prevalence in different regions of the brain. Additionally, we have analysed how this information may affect tumours' molecular characteristics, treatment options offered to patients, and patients' overall survival. This information will be informative both in the clinical setting and in directing future research.
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http://dx.doi.org/10.5603/PJNNS.a2020.0067DOI Listing
November 2020

Sex-specific impact of patterns of imageable tumor growth on survival of primary glioblastoma patients.

BMC Cancer 2020 May 19;20(1):447. Epub 2020 May 19.

Precision Neurotherapeutics Innovation Program, Mayo Clinic, 5777 East Mayo Blvd , SSB 02-700, Phoenix, AZ, 85054, USA.

Background: Sex is recognized as a significant determinant of outcome among glioblastoma patients, but the relative prognostic importance of glioblastoma features has not been thoroughly explored for sex differences.

Methods: Combining multi-modal MR images, biomathematical models, and patient clinical information, this investigation assesses which pretreatment variables have a sex-specific impact on the survival of glioblastoma patients (299 males and 195 females).

Results: Among males, tumor (T1Gd) radius was a predictor of overall survival (HR = 1.027, p = 0.044). Among females, higher tumor cell net invasion rate was a significant detriment to overall survival (HR = 1.011, p < 0.001). Female extreme survivors had significantly smaller tumors (T1Gd) (p = 0.010 t-test), but tumor size was not correlated with female overall survival (p = 0.955 CPH). Both male and female extreme survivors had significantly lower tumor cell net proliferation rates than other patients (M p = 0.004, F p = 0.001, t-test).

Conclusion: Despite similar distributions of the MR imaging parameters between males and females, there was a sex-specific difference in how these parameters related to outcomes.
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http://dx.doi.org/10.1186/s12885-020-06816-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238585PMC
May 2020
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