Publications by authors named "Gabriel Zada"

233 Publications

Commentary: Infra-Occipital Supra-Tentorial Approach for Resection of Low-Grade Tumor of the Left Lingual Gyrus: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Jun 10. Epub 2021 Jun 10.

Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

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http://dx.doi.org/10.1093/ons/opab178DOI Listing
June 2021

Commentary: Application of Augmented Reality in Percutaneous Procedures-Rhizotomy of the Gasserian Ganglion.

Oper Neurosurg (Hagerstown) 2021 Jun 7. Epub 2021 Jun 7.

Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

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http://dx.doi.org/10.1093/ons/opab179DOI Listing
June 2021

Bilateral arachnoid cyst-associated subdural fluid collections in an infant following TBI.

J Forensic Leg Med 2021 May 21;81:102189. Epub 2021 May 21.

Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, United States.

Introduction: arachnoid cyst-associated subdural fluid collections have been documented in children and adults following traumatic brain injury (TBI). However, this phenomenon has not been previously demonstrated in infants less than 12 months of age. We present a case of an infant with bilateral arachnoid cyst-associated subdural fluid collections identified after TBI.

Case Presentation: a 9-month-old female infant with profound macrocephaly presented to medical care with altered mental status following a witnessed fall down steps while unsecured in a stroller. Neuroimaging revealed bilateral subdural fluid collections, in addition to a hyperdense subdural hematoma, that raised concern for abusive head trauma (AHT) among the pediatric inpatient team and the hospital's Suspected Child Abuse and Neglect (SCAN) Team was consulted. After excluding occult abusive injuries as well as testing for underlying medical conditions, the infant's bilateral subdural fluid collections were attributed to rupture of a pre-existing left middle cranial fossa arachnoid cyst with evidence of prior macrocephaly.

Conclusion: In infants and toddlers, the identification of subdural fluid collections on neuroimaging warrants inclusion of AHT in the differential diagnosis. However, in infants with a history of congenital macrocephaly, and an otherwise negative AHT workup, an accidental mechanism for the formation of subdural collections should be considered, especially when co-occurring with an arachnoid cyst.
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http://dx.doi.org/10.1016/j.jflm.2021.102189DOI Listing
May 2021

Noninvasive transcranial classification of stroke using a portable eddy current damping sensor.

Sci Rep 2021 May 13;11(1):10297. Epub 2021 May 13.

Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA.

Existing paradigms for stroke diagnosis typically involve computed tomography (CT) imaging to classify ischemic versus hemorrhagic stroke variants, as treatment for these subtypes varies widely. Delays in diagnosis and transport of unstable patients may worsen neurological status. To address these issues, we describe the development of a rapid, portable, and accurate eddy current damping (ECD) stroke sensor. Copper wire was wound to create large (11.4 cm), medium (4.5 cm), and small (1.5 cm) solenoid coils with varying diameters, with each connected to an inductance-to-digital converter. Eight human participants were recruited between December 15, 2019 and March 15, 2020, including two hemorrhagic stroke, two ischemic stroke, one subarachnoid hemorrhage, and three control participants. Observers were blinded to lesion type and location. A head cap with 8 horizontal scanning paths was placed on the patient. The sensor was tangentially rotated across each row on the patient's head circumferentially. Consent, positioning, and scanning with the sensor took roughly 15 min from start to end for each participant and all scanning took place at the patient bedside. The ECD sensor accurately classified and imaged each of the varying stroke types in each patient. The sensor additionally detected ischemic and hemorrhagic lesions located deep inside the brain, and its range is selectively tunable during sensor design and fabrication.
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http://dx.doi.org/10.1038/s41598-021-89735-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8119677PMC
May 2021

Stereotactic Radiosurgery for Differentiated Thyroid Cancer Brain Metastases: An International, Multicenter Study.

Thyroid 2021 May 11. Epub 2021 May 11.

Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.

Brain metastases (BM) from differentiated thyroid cancer are rare. Stereotactic radiosurgery (SRS) is commonly used for the treatment of BMs; however, the experience with SRS for thyroid cancer BMs remains limited. The goal of this international, multi-centered study was to evaluate the efficacy and safety of SRS for thyroid cancer BMs. From 10 institutions participating in the International Radiosurgery Research Foundation, we pooled patients with established papillary or follicular thyroid cancer diagnosis who underwent SRS for histologically confirmed or radiologically suspected BMs. We investigated patient overall survival (OS), local tumor control, and adverse radiation events (AREs). We studied 42 (52% men) patients who underwent SRS for 122 papillary (83%) or follicular (17%) thyroid cancer BMs. The mean age at SRS was 59.86 ± 12.69 years. The mean latency from thyroid cancer diagnosis to SRS for BMs was 89.05 ± 105.49 months. The median number of BMs per patient was 2 (range: 1-10 BMs). The median SRS treatment volume was 0.79 cm (range: 0.003-38.18 cm), and the median SRS prescription dose was 20 Gy (range: 8-24 Gy). The median survival after SRS for BMs was 14 months (range: 3-58 months). The OS was significantly shorter in patients harboring ≥2 BMs, when compared with patients with one BM (Log-rank = 5.452,  = 0.02). Two or more BMs (odds ratio [OR] = 3.688; confidence interval [CI]: 1.143-11.904;  = 0.03) and lower Karnofsky performance score at the time of SRS (OR = 0.807; CI: 0.689-0.945;  = 0.008) were associated with shorter OS. During post-SRS imaging follow-up of 25.21 ± 30.49 months, local failure (progression and/or radiation necrosis) of BMs treated with SRS was documented in five (4%) BMs at 7.2 ± 7.3 months after the SRS. At the last imaging follow-up, the majority of patients with available imaging data had stable intracranial disease (33%) or achieved complete (26%) or partial (24%) response. There were no clinical AREs. Post-SRS peritumoral T2/fluid attenuated inversion recovery signal hyperintensity was noted in 7% BMs. The SRS allows durable local control of papillary and follicular thyroid cancer BMs in the vast majority of patients. Higher number of BMs and worse functional status at the time of SRS are associated with shorter OS in patients with thyroid cancer BMs. The SRS is safe and is associated with a low risk of AREs.
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http://dx.doi.org/10.1089/thy.2020.0947DOI Listing
May 2021

Silent corticotroph pituitary adenomas: clinical characteristics, long-term outcomes, and management of disease recurrence.

J Neurosurg 2021 May 7:1-8. Epub 2021 May 7.

Departments of1Neurological Surgery.

Objective: Silent corticotroph adenomas (SCAs) are a distinct subtype of nonfunctioning pituitary adenomas (NFAs) that demonstrate positive immunohistochemistry for adrenocorticotropic hormone (ACTH) without causing Cushing's disease. SCAs are hypothesized to exhibit more aggressive behavior than standard NFAs. The authors analyzed their institution's surgical experience with SCAs in an effort to characterize rates of invasion, postoperative clinical outcomes, and patterns of disease recurrence and progression. The secondary objectives were to define the best treatment strategies in the event of tumor recurrence and progression.

Methods: A retrospective analysis of patients treated at the authors' institution identified 100 patients with SCAs and 841 patients with NFAs of other subtypes who were treated surgically from 2000 to 2019. Patient demographics, tumor characteristics, surgical and neuroimaging data, rates of endocrinopathy, and neurological outcomes were recorded. Cohorts of patients with SCAs and patients with standard NFAs were compared with regard to these characteristics and outcomes.

Results: The SCA cohort presented with cranial neuropathy (13% vs 5.7%, p = 0.0051) and headache (53% vs 42.3%, p = 0.042) compared to the NFA cohort, despite similar rates of apoplexy. The SCA cohort included a higher proportion of women (SCA 60% vs NFA 45.8%, p = 0.0071) and younger age at presentation (SCA 50.5 ± 13.3 vs NFA 54.6 ± 14.9 years of age, p = 0.0082). Reoperations were comparable between the cohorts (SCA 16% vs NFA 15.7%, p = 0.98). Preoperative pituitary function was comparable between the cohorts with the exception of higher rates of preoperative panhypopituitarism in NFA patients (2% vs 6.1%, respectively; p = 0.0033). The mean tumor diameter in SCA patients was 24 ± 10.8 mm compared to 26 ± 11.3 mm in NFA patients (p = 0.05). Rates of cavernous sinus invasion were higher in the SCA group (56% vs 49.7%), although this result did not reach statistical significance. There were no significant differences in extent of resection, intraoperative CSF leak rates, endocrine or neurological outcomes, or postoperative complications. Ki-67 rates were significantly increased in the SCA cohort (2.88 ± 2.79) compared to the NFA cohort (1.94 ± 1.99) (p = 0.015). Although no differences in overall rates of progression or recurrence were noted, SCAs had a significantly lower progression-free survival (24.5 vs 51.1 months, p = 0.0011). Among the SCA cohort, progression was noted despite the use of adjuvant radiosurgery in 33% (n = 4/12) of treated tumors. Adequate tumor control was not achieved in half (n = 6) of the SCA progression cohort despite radiosurgery or multiple resections.

Conclusions: In this study, to the authors' knowledge the largest surgical series to assess outcomes in SCAs to date, the findings suggest that SCAs are more biologically aggressive tumors than standard NFAs. The progression-free survival duration of patients with SCAs is only about half that of patients with other NFAs. Therefore, close neuroimaging and clinical follow-up are warranted in patients with SCAs, and residual disease should be considered for early postoperative adjuvant radiosurgery, particularly in younger patients.
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http://dx.doi.org/10.3171/2020.10.JNS203236DOI Listing
May 2021

Complementary and Alternative Medicine for the Treatment of Gliomas: Scoping Review of Clinical Studies, Patient Outcomes, and Toxicity Profiles.

World Neurosurg 2021 Apr 30. Epub 2021 Apr 30.

USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.

Introduction: Complementary and alternative medicine (CAM) are highly used among those diagnosed with glioma. Further research is warranted, however, as it remains important to clearly delineate CAM practices that are unproven, disproven, or promising for future research and implementation.

Methods: A systematic review was conducted to identify all articles that investigated the effect of any CAM therapy on survival of patients with newly diagnosed or recurrent glioma.

Results: Eighteen papers and 4 abstracts pertaining to the effects of ketogenic diet (4), antioxidants (3), hyperbaric oxygen (4), cannabinoids (2), carbogen and nicotinamide (3), mistletoe extract (2), hypocupremia and penicillamine (1), and overall CAM use (3) on overall and progression-free survival in patients with low- and high-grade glioma were identified (Levels of Evidence I-IV). Ketogenic diets, hyperbaric oxygen therapy, and cannabinoids appear to be safe and well tolerated by patients; preliminary studies demonstrate tumor response and increased progression-free survival and overall survival when combined with standard of care therapies. Antioxidant usage exhibit mixed results perhaps associated with glioma grade with greater effect on low-grade gliomas; vitamin D intake was associated with prolonged survival. Conversely, carbogen breathing and hypocupremia were found to have no effect on the survival of patients with glioma, with associated significant toxicity. Most modalities under the CAM umbrella have not been appropriately studied and require further investigation.

Conclusions: Despite widespread use, Level I or II evidence for CAM for the treatment of glioma is lacking, representing future research directions to optimally counsel and treat glioma patients.
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http://dx.doi.org/10.1016/j.wneu.2021.04.096DOI Listing
April 2021

The role of reoperation after recurrence of Cushing's disease.

Best Pract Res Clin Endocrinol Metab 2021 Mar 6;35(2):101489. Epub 2021 Feb 6.

USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, 1300 N. State Street, Suite 3300, Los Angeles, CA, 90033, USA; Department of Medicine, Division of Endocrinology and Diabetes, Keck School of Medicine of University of Southern California, 1333 San Pablo Street, BMT-B11, Los Angeles, CA, 90033, USA. Electronic address:

Surgical failure or recurrence of Cushing's disease can be treated with medical therapy, radiotherapy, adrenalectomy, and/or repeat transsphenoidal surgery, all of which have their respective benefits and drawbacks. Redo transsphenoidal surgery has been shown to achieve at least short-term remission in about 40-80% of patients and is associated with low rates of morbidity and near-zero mortality, albeit higher rates of postoperative hypopituitarism, diabetes insipidus, and cerebrospinal fluid leak than initial resection. Despite this, recurrence may ensue in 50% of patients. When selecting patient candidates for reoperation, many predictors of postoperative outcomes have been proposed including imaging characteristics, histopathological staining, intraoperative tumor visualization, and tumor size, however no single predictor consistently predicts outcomes. Redo transsphenoidal surgery should be performed by an experienced pituitary surgeon and patients should be followed at a tertiary care center by a multidisciplinary team consisting of an experienced endocrinologist and neurosurgeon to monitor closely for remission and recurrence.
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http://dx.doi.org/10.1016/j.beem.2021.101489DOI Listing
March 2021

Use of Salvage Surgery or Stereotactic Radiosurgery for Multiply Recurrent Skull Base Chordomas: A Single-Institution Experience and Review of the Literature.

J Neurol Surg B Skull Base 2021 Apr 14;82(2):161-174. Epub 2020 Jan 14.

Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, California, United States.

 Chordomas are locally destructive neoplasms characterized by appreciable recurrence rates after initial multimodality treatment. We examined the outcome of salvage treatment in recurrent/progressive skull base chordomas.  This is a retrospective review of recurrent/progressive skull base chordomas at a tertiary urban academic medical center. The outcomes evaluated were overall survival, progression-free survival (PFS), and incidence of new toxicity.  Eighteen consecutive patients who underwent ≥1 course of treatment (35.3% salvage surgery, 23.5% salvage radiation, and 41.2% both) were included. The median follow-up was 98.6 months (range 16-215 months). After initial treatment, the median PFS was 17.7 months (95% confidence interval [CI]: 4.9-22.6 months). Following initial therapy, age ≥ 40 had improved PFS on univariate analysis (  = 0.03). All patients had local recurrence, with 15 undergoing salvage surgical resections and 16 undergoing salvage radiation treatments (mostly stereotactic radiosurgery [SRS]). The median PFS was 59.2 months (95% CI: 4.0-99.3 months) after salvage surgery, 58.4 months (95% CI: 25.9-195 months) after salvage radiation, and 58.4 months (95% CI: 25.9.0-98.4 months) combined. Overall survival for the total cohort was 98.7% ± 1.7% at 2 years and 92.8% ± 5.5% at 5 years. Salvage treatments were well-tolerated with two patients (11%) reporting tinnitus and one patient each (6%) reporting headaches, visual field deficits, hearing loss, anosmia, dysphagia, or memory loss.  Refractory skull base chordomas present a challenging treatment dilemma. Repeat surgical resection or SRS seems to provide adequate salvage therapy that is well-tolerated when treated at a tertiary center offering multimodality care.
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http://dx.doi.org/10.1055/s-0039-3402019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987397PMC
April 2021

Improved surgeon performance following cadaveric simulation of internal carotid artery injury during endoscopic endonasal surgery: training outcomes of a nationwide prospective educational intervention.

J Neurosurg 2021 Mar 19:1-9. Epub 2021 Mar 19.

Departments of1Neurosurgery and.

Objective: Internal carotid artery injury (ICAI) is a rare, life-threatening complication of endoscopic endonasal approaches that will be encountered by most skull base neurosurgeons and otolaryngologists. Rates of surgical proficiency for managing ICAI are not known, and the role of simulation to improve performance has not been studied on a nationwide scale.

Methods: Attending and resident neurosurgery and otorhinolaryngology surgeons (n = 177) were recruited from multicenter regional and national training courses to assess training outcomes and validity at scale of a prospective educational intervention to improve surgeon technical skills using a previously validated, perfused human cadaveric simulator. Participants attempted an initial trial (T1) of simulated ICAI control using their preferred technique. An educational intervention including personalized instruction was performed. Participants attempted a second trial (T2). Task success (dichotomous), time to hemostasis (TTH), estimated blood loss (EBL), and surgeon heart rate were measured.

Results: Participant rating scales confirmed that the simulation retained face and construct validity across eight instructional settings. Trial success (ICAI control) improved from 56% in T1 to 90% in T2 (p < 0.0001). EBL and TTH decreased by 37% and 38%, respectively (p < 0.0001). Postintervention resident surgeon performance (TTH, EBL, and success rate) was superior to preintervention attending surgeon performance. The most improved quartile of participants achieved 62% improvement in TTH and 73% improvement in EBL, with trial success improvement from 25.6% in T1 to 100% in T2 (p < 0.0001). Baseline surgeon confidence was uncorrelated with T1 success, while posttraining confidence correlated with T2 success. Tachycardia was measured in 57% of surgeon participants, but was attenuated during T2, consistent with development of resiliency.

Conclusions: Prior to training, many attending and most resident surgeons could not manage the rare, life-threatening intraoperative complication of ICAI. A simulated educational intervention significantly improved surgeon performance and remained valid when deployed at scale. Simulation also promoted the development of favorable cognitive skills (accurate perception of skill and resiliency). Rare, life-threatening intraoperative complications may be optimal targets for educational interventions using surgical simulation.
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http://dx.doi.org/10.3171/2020.9.JNS202672DOI Listing
March 2021

A Guide to Annotation of Neurosurgical Intraoperative Video for Machine Learning Analysis and Computer Vision.

World Neurosurg 2021 Jun 17;150:26-30. Epub 2021 Mar 17.

Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Division of Neurosurgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.

Objective: Computer vision (CV) is a subset of artificial intelligence that performs computations on image or video data, permitting the quantitative analysis of visual information. Common CV tasks that may be relevant to surgeons include image classification, object detection and tracking, and extraction of higher order features. Despite the potential applications of CV to intraoperative video, however, few surgeons describe the use of CV. A primary roadblock in implementing CV is the lack of a clear workflow to create an intraoperative video dataset to which CV can be applied. We report general principles for creating usable surgical video datasets and the result of their applications.

Methods: Video annotations from cadaveric endoscopic endonasal skull base simulations (n = 20 trials of 1-5 minutes, size = 8 GB) were reviewed by 2 researcher-annotators. An internal, retrospective analysis of workflow for development of the intraoperative video annotations was performed to identify guiding practices.

Results: Approximately 34,000 frames of surgical video were annotated. Key considerations in developing annotation workflows include 1) overcoming software and personnel constraints; 2) ensuring adequate storage and access infrastructure; 3) optimization and standardization of annotation protocol; and 4) operationalizing annotated data. Potential tools for use include CVAT (Computer Vision Annotation Tool) and Vott: open-sourced annotation software allowing for local video storage, easy setup, and the use of interpolation.

Conclusions: CV techniques can be applied to surgical video, but challenges for novice users may limit adoption. We outline principles in annotation workflow that can mitigate initial challenges groups may have when converting raw video into useable, annotated datasets.
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http://dx.doi.org/10.1016/j.wneu.2021.03.022DOI Listing
June 2021

Thermal Conductance Through the Skull Base From Endoscopic Surgery Cauterization Instruments: Cadaver and Goat Model.

Otolaryngol Head Neck Surg 2021 Mar 9:1945998211000372. Epub 2021 Mar 9.

Tina and Rick Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.

Objective: Cauterization prevents hemorrhage and optimizes the surgical field during endoscopic sinus surgery but may cause injury to nearby structures. The objective of this study is to examine thermal conductance from cauterization equipment across the skull base.

Study Design: Cadaver and animal model.

Setting: Surgical skills laboratory of an academic tertiary medical institution.

Methods: A pilot study was conducted with a deidentified cadaver head and expanded to a goat head animal model. Endoscopic dissection was performed to expose the lamina papyracea, ethmoid roof, sphenoid roof, and frontal sinus. Cautery was applied to the frontal sinus of goat heads, and temperatures were measured via thermocouple sensors placed along the intracranial skull base. Surgical instruments studied included monopolar, bipolar, and endoscopic bipolar devices at various power settings.

Results: Temperature increase, as averaged across all cautery powers and measurement positions, was highest for the monopolar cautery (17.55 °C) when compared with the bipolar and endoscopic bipolar devices (<2 °C for bipolar, Endo-Pen, Stammberger, and Wormald; < .001). Monopolar cautery reached 30.86 °C at high power when averaged over all positions ( < .001) as compared with <3 °C for the other instruments. Temperatures rose as power of cautery was increased from low to medium and high. Temperatures decreased as the distance of the thermocouple sensor probe from the cautery origin increased.

Conclusion: Thermal conductance across the skull base varies depending on equipment and power of cautery, with monopolar resulting in the largest temperature increase. Choice and implementation of cauterization instruments have implications on inadvertent transmission of thermal energy during endoscopic sinus surgery.
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http://dx.doi.org/10.1177/01945998211000372DOI Listing
March 2021

Demographic-Dependent Risk of Developing Severe Novel Psychiatric Disorders after Concussion.

J Neurotrauma 2021 Apr 26. Epub 2021 Apr 26.

Department of Neurosurgery, and Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Current guidelines for patients experiencing a concussion or mild traumatic brain injury (mTBI) often focus on conservative care and observation. However, mTBI may increase the risk of severe novel psychiatric disorders (NPDs) within 180 days, and long-term management of mTBI should include psychiatric evaluation in patient populations. Retrospective cohort analysis was conducted using 8 years of the Nationwide Readmission Database. All individuals who were admitted for concussion and were readmitted within 180 days were queried. This cohort was then subdivided based on age, sex, and whether they experienced loss of consciousness (LOC) to control for demographic-dependent confounding. A binary decision tree provided recommendations for patients who may be at risk of developing severe NPDs. Analysis included 12,080 patients who experienced concussion. Males and females with LOC had higher rates of depression in all age quartiles within 180 days ( < 0.05). Young females with LOC had increased rates of suicidal ideation ( < 0.01), and those >25 years of age had increased rates of anxiety ( < 0.005). Adult males with LOC had increased rates of suicidal ideation ( < 0.002) and males >75 years of age had increased rates of anxiety at readmission ( < 0.05). Males without LOC had increased rates of depression ( < 0.005), with men in the second quartile also at higher risk of developing anxiety ( < 0.05). Females without LOC showed the fewest number of NPDs at readmission. Concussion may be associated with increased rates of NPDs in the first 6 months following discharge. We use these data to develop recommendations for psychiatric screening of patients with mTBI.
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http://dx.doi.org/10.1089/neu.2020.7467DOI Listing
April 2021

Comorbid depression in surgical cancer patients associated with non-routine discharge and readmission.

Surg Oncol 2021 Feb 12;37:101533. Epub 2021 Feb 12.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Objective: To characterize the rates of depression across primary cancer sites, and determine the effects of comorbid depression among surgical cancer patients on established quality of care indicators, non-routine discharge and readmission.

Methods: Patients undergoing surgical resection for cancer were selected from the Nationwide Readmissions Database (2010-2014). Multivariable analysis adjusted for patient and hospital level characteristics to ascertain the effect of depression on post-operative outcomes and 30-day readmission rates. Non-routine discharge encompasses discharge to skilled nursing, inpatient rehabilitation, and intermediate care facilities, as well as discharge home with home health services.

Results: Among 851,606 surgically treated cancer patients, 8.1% had a comorbid diagnosis of depression at index admission (n = 69,174). Prevalence of depression was highest among patients with cancer of the brain (10.9%), female genital organs (10.9%), and lung (10.5%), and lowest among those with prostate cancer (4.9%). Depression prevalence among women (10.9%) was almost twice that of men (5.7%). Depression was associated with non-routine discharge after surgery (OR 1.20, CI:1.18-1.23, p < 0.0001*) and hospital readmission within 30 days (OR 1.12, CI:1.09-1.15, p < 0.001*).

Conclusion: Rates of depression vary amongst surgically treated cancer patients by primary tumor site. Comorbid depression in these patients is associated with increased likelihood of non-routine discharge and readmission.
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http://dx.doi.org/10.1016/j.suronc.2021.101533DOI Listing
February 2021

Prevalence Rate of Coexisting Rathke Cleft Cysts and Pineal Cysts: A Multicenter Cross-Sectional Study.

World Neurosurg 2021 May 7;149:e455-e459. Epub 2021 Feb 7.

Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Rathke cleft cysts (RCCs) are benign sellar lesions originating from remnants of primitive ectoderm. They have not been previously linked to other cystic lesions, such as pineal cysts (PCs). Our objective was to perform a multicenter cross-sectional neuroimaging study to examine prevalence rates of coexisting RCC and PC.

Methods: We retrospectively queried prospectively maintained, institutional review board-approved, databases from the authors' centers. All patients undergoing transsphenoidal surgery for RCC between the years of 2011 and 2020 were included for analysis. Preoperative magnetic resonance imaging was reviewed to identify the coexistence of a PC. Patient demographics and neuroimaging characteristics were recorded. A control cohort comprised of 100 age- and sex-matched patients with nonfunctional pituitary adenoma (NFPA) who also underwent surgical intervention was utilized.

Results: Eighty-four patients with RCC were identified for analysis. A coexistent PC was identified in 40.5% (n = 34) of patients with RCC compared with 14.3% (n = 12) in the NFPA cohort (P < 0.001). There was no significant difference in PC size between patients with RCC and PA (8 vs. 8.8 mm, respectively; P = 0.77). Although the majority (85.7%; n = 72) of the RCC cohort were female patients, there was no sex predominance with respect to coexisting PC in either the RCC or PA cohort.

Conclusions: This is the first study to report an increased prevalence of coexisting PC and RCC, possibly because of an embryologic link or other propensity for intracranial cyst formation. Additional studies in more generalizable populations can further explore the relation between RCC and PC, or other cyst formation.
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http://dx.doi.org/10.1016/j.wneu.2021.02.004DOI Listing
May 2021

Tracking Scan to Incision Time in Patients with Emergent Operative Traumatic Brain Injuries as a Measure for Systems-Based Practice in Neurosurgical Trainees.

World Neurosurg 2021 May 5;149:e491-e497. Epub 2021 Feb 5.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Evaluation of trainee performance remains a challenge in resident education, particularly for systems-based practice (SysBP) metrics including care coordination and interdisciplinary teamwork. Time to intervention is an important modifiable outcome variable in severe traumatic brain injury (TBI) and may serve as a trackable metric for SysBP evaluation.

Methods: We retrospectively studied time from computed tomography head scan to surgical incision (CTH-INC, minutes) among neurosurgical trainees treating patients with emergently operative TBI as a proxy SysBP measure. Our institutional operative database was utilized to identify all emergent TBI cases between July 2015 and June 2020. Patients evaluated by program year (PGY)-2 residents proceeding directly to the operating room from the emergency department were included. Statistical analysis was performed using linear regression.

Results: One hundred sixty-six cases triaged by 14 PGY-2 neurosurgical trainees were analyzed. Median CTH-INC was 104 minutes (interquartile range, 82-136 minutes). CTH-INC improved 20.1% over the academic year (95% confidence interval, 4.3%-33.2%, P = 0.015). Between the first and second 6-month periods, the rate of CTH-INC within 90 minutes (29% vs. 46%, P = 0.04) improved. On a per-individual PGY-2 basis, median CTH-INC ranged from 83-127 minutes, 25th percentile CTH-INC ranged from 62-108 minutes, and fastest CTH-INC ranged from 45-92 minutes.

Conclusions: CTH-INC is an objective and trackable proxy measure for evaluating SysBP during neurosurgical training. Use of CTH-INC or other time metrics in resident evaluations should not supersede the safe and effective delivery of patient care.
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http://dx.doi.org/10.1016/j.wneu.2021.01.150DOI Listing
May 2021

Treatment of WHO Grade 2 Meningiomas With Stereotactic Radiosurgery: Identification of an Optimal Group for SRS Using RPA.

Int J Radiat Oncol Biol Phys 2021 Jul 3;110(3):804-814. Epub 2021 Feb 3.

Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia.

Purpose: This study assesses a large multi-institutional database to present the outcomes of World Health Organization grade 2 meningiomas treated with stereotactic radiosurgery (SRS). We also compare the 3-year progression-free survival (PFS) to that reported in the Radiation Therapy Oncology Group 0539 phase 2 cooperative group meningioma trial.

Methods And Materials: From an international, multicenter group, data were collected for grade 2 meningioma patients treated with SRS for demonstrable tumor from 1994 to 2019. Statistical methods used included the Kaplan-Meier method, Cox proportional hazards analysis, and recursive partitioning analysis.

Results: Two hundred thirty-three patients treated at 12 institutions were included. Patients presented at a median age of 60 years (range, 13-90), and many had at least 2 prior resections (30%) or radiation therapy (22%). Forty-eight percent of patients had prior gross total resection. At SRS, the median treatment volume was 6.1 cm (0.1-97.6). A median 15 Gy (10-30) was delivered to a median percent isodose of 50 (30-80), most commonly in 1 fraction (95%). A model was developed using recursive partitioning analysis, with one point attributed to age >50 years, treatment volume >11.5 cm, and prior radiation therapy or multiple surgeries. The good-prognostic group (score, 0-1) had improved PFS (P < .005) and time to local failure (P < .005) relative to the poor-prognostic group (score, 2-3). Age >50 years (hazard ratio = 1.85 [95% confidence interval, 1.09-3.14]) and multiple prior surgeries (hazard ratio = 1.80 [1.09-2.99]) also portended reduced PFS in patients without prior radiation therapy. Two hundred eighteen of 233 patients in this study qualified for the high-risk group of Radiation Therapy Oncology Group 0539, and they demonstrated similar outcomes (3-year PFS: 53.9% vs 58.8%). The good-prognostic group of SRS patients demonstrated slightly improved outcomes (3-year PFS: 63.1% vs 58.8%).

Conclusions: SRS should be considered in carefully selected patients with atypical meningiomas. We suggest the use of our good-prognostic group to optimize patient selection, and we strongly encourage the initiation of a clinical trial to prospectively validate these outcomes.
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http://dx.doi.org/10.1016/j.ijrobp.2021.01.048DOI Listing
July 2021

Neural network modeling for prediction of recurrence, progression, and hormonal non-remission in patients following resection of functional pituitary adenomas.

Pituitary 2021 Feb 2. Epub 2021 Feb 2.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Purpose: Functional pituitary adenomas (FPAs) cause severe neuro-endocrinopathies including Cushing's disease (CD) and acromegaly. While many are effectively cured following FPA resection, some encounter disease recurrence/progression or hormonal non-remission requiring adjuvant treatment. Identification of risk factors for suboptimal postoperative outcomes may guide initiation of adjuvant multimodal therapies.

Methods: Patients undergoing endonasal transsphenoidal resection for CD, acromegaly, and mammosomatotroph adenomas between 1992 and 2019 were identified. Good outcomes were defined as hormonal remission without imaging/biochemical evidence of disease recurrence/progression, while suboptimal outcomes were defined as hormonal non-remission or MRI evidence of recurrence/progression despite adjuvant treatment. Multivariate regression modeling and multilayered neural networks (NN) were implemented. The training sets randomly sampled 60% of all FPA patients, and validation/testing sets were 20% samples each.

Results: 348 patients with mean age of 41.7 years were identified. Eighty-one patients (23.3%) reported suboptimal outcomes. Variables predictive of suboptimal outcomes included: Requirement for additional surgery in patients who previously had surgery and continue to have functionally active tumor (p = 0.0069; OR = 1.51, 95%CI 1.12-2.04), Preoperative visual deficit not improved after surgery (p = 0.0033; OR = 1.12, 95%CI 1.04-1.20), Transient diabetes insipidus (p = 0.013; OR = 1.27, 95%CI 1.05-1.52), Higher MIB-1/Ki-67 labeling index (p = 0.038; OR = 1.08, 95%CI 1.01-1.15), and preoperative low cortisol axis (p = 0.040; OR = 2.72, 95%CI 1.06-7.01). The NN had overall accuracy of 87.1%, sensitivity of 89.5%, specificity of 76.9%, positive predictive value of 94.4%, and negative predictive value of 62.5%. NNs for all FPAs were more robust than for CD or acromegaly/mammosomatotroph alone.

Conclusion: We demonstrate capability of predicting suboptimal postoperative outcomes with high accuracy. NNs may aid in stratifying patients for risk of suboptimal outcomes, thereby guiding implementation of adjuvant treatment in high-risk patients.
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http://dx.doi.org/10.1007/s11102-021-01128-5DOI Listing
February 2021

Stereotactic Radiosurgery for Perioptic Meningiomas: An International, Multicenter Study.

Neurosurgery 2021 03;88(4):828-837

Department of Radiation Oncology, University of Colorado, Denver, Colorado.

Background: Stereotactic radiosurgery (SRS) is increasingly used for management of perioptic meningiomas.

Objective: To study the safety and effectiveness of SRS for perioptic meningiomas.

Methods: From 12 institutions participating in the International Radiosurgery Research Foundation (IRRF), we retrospectively assessed treatment parameters and outcomes following SRS for meningiomas located within 3 mm of the optic apparatus.

Results: A total of 438 patients (median age 51 yr) underwent SRS for histologically confirmed (29%) or radiologically suspected (71%) perioptic meningiomas. Median treatment volume was 8.01 cm3. Median prescription dose was 12 Gy, and median dose to the optic apparatus was 8.50 Gy. A total of 405 patients (93%) underwent single-fraction SRS and 33 patients (7%) underwent hypofractionated SRS. During median imaging follow-up of 55.6 mo (range: 3.15-239 mo), 33 (8%) patients experienced tumor progression. Actuarial 5-yr and 10-yr progression-free survival was 96% and 89%, respectively. Prescription dose of ≥12 Gy (HR: 0.310; 95% CI [0.141-0.679], P = .003) and single-fraction SRS (HR: 0.078; 95% CI [0.016-0.395], P = .002) were associated with improved tumor control. A total of 31 (10%) patients experienced visual decline, with actuarial 5-yr and 10-yr post-SRS visual decline rates of 9% and 21%, respectively. Maximum dose to the optic apparatus ≥10 Gy (HR = 2.370; 95% CI [1.086-5.172], P = .03) and tumor progression (HR = 4.340; 95% CI [2.070-9.097], P < .001) were independent predictors of post-SRS visual decline.

Conclusion: SRS provides durable tumor control and quite acceptable rates of vision preservation in perioptic meningiomas. Margin dose of ≥12 Gy is associated with improved tumor control, while a dose to the optic apparatus of ≥10 Gy and tumor progression are associated with post-SRS visual decline.
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http://dx.doi.org/10.1093/neuros/nyaa544DOI Listing
March 2021

Stereotactic Radiosurgery for Atypical (World Health Organization II) and Anaplastic (World Health Organization III) Meningiomas: Results From a Multicenter, International Cohort Study.

Neurosurgery 2021 04;88(5):980-988

Department of Neurologic Surgery, Mayfield Clinic, Cincinnati, Ohio.

Background: Atypical and anaplastic meningiomas have reduced progression-free/overall survival (PFS/OS) compared to benign meningiomas. Stereotactic radiosurgery (SRS) for atypical meningiomas (AMs) and anaplastic meningiomas (malignant meningiomas, MMs) has not been adequately described.

Objective: To define clinical/radiographic outcomes for patients undergoing SRS for AM/MMs.

Methods: An international, multicenter, retrospective cohort study was performed to define clinical/imaging outcomes for patients receiving SRS for AM/MMs. Tumor progression was assessed with response assessment in neuro-oncology (RANO) criteria. Factors associated with PFS/OS were assessed using Kaplan-Meier analysis and a Cox proportional hazards model.

Results: A total of 271 patients received SRS for AMs (n = 233, 85.9%) or MMs (n = 38, 14.0%). Single-fraction SRS was most commonly employed (n = 264, 97.4%) with a mean target dose of 14.8 Gy. SRS was used as adjuvant treatment (n = 85, 31.4%), salvage therapy (n = 182, 67.2%), or primary therapy (1.5%). The 5-yr PFS/OS rate was 33.6% and 77.0%, respectively. Increasing age (hazard ratio (HR) = 1.01, P < .05) and a Ki-67 index > 15% (HR = 1.66, P < .03) negatively correlated with PFS. MMs (HR = 3.21, P < .05), increased age (HR = 1.04, P = .04), and reduced KPS (HR = 0.95, P = .04) were associated with shortened OS. Adjuvant versus salvage SRS did not impact PFS/OS. A shortened interval between surgery and SRS improved PFS for AMs (HR = 0.99, P = .02) on subgroup analysis. Radiation necrosis occurred in 34 (12.5%) patients. Five-year rates of repeat surgery/radiation were 33.8% and 60.4%, respectively.

Conclusion: AM/MMs remain challenging tumors to treat. Elevated proliferative indices are associated with tumor recurrence, while MMs have worse survival. SRS can control AM/MMs in the short term, but the 5-yr PFS rates are low, underscoring the need for improved treatment options for these patients.
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http://dx.doi.org/10.1093/neuros/nyaa553DOI Listing
April 2021

Safety and Effectiveness of the Direct Endoscopic Endonasal Approach for Primary Sellar Pathology: A Contemporary Case Series of More Than 400 Patients.

World Neurosurg 2021 Apr 14;148:e536-e546. Epub 2021 Jan 14.

USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: The direct endoscopic endonasal approach (EEA) has become the primary technique used for resection of sellar pathology, meriting investigation into the risk factors for complications and predictors of postoperative outcomes after direct EEA.

Methods: We retrospectively analyzed the patient and tumor characteristics from 404 patients who had undergone direct EEA for sellar pathology at the USC Pituitary Center from September 2011 to December 2019.

Results: Of the 404 pathologic entities included, 349 (86%) were pituitary adenomas (PAs), 29 (7%) were Rathke cleft cysts, and 26 (6%) were other sellar lesions. The mean lesion diameter was 2.3 cm, with 34 microadenomas (10%) and 315 macroadenomas (90%). Cavernous sinus invasion was present in 39% of the PAs. No patient died. The surgical complications included internal carotid artery injury without neurological sequelae (0.2%), vision loss (0.7%), meningitis (0.7%), cerebrospinal fluid leak (4%), epistaxis (4%), sinusitis (1%), transient cranial nerve paresis (0.5%), and postoperative abscess (0.25%). New hypopituitarism developed in 3%. Gross total resection was achieved in 208 PA cases (58%). Clinical improvement of headaches and visual deficits were reported for 67% and 76% of cases, respectively. Hormonal remission was achieved in 82% of patients with functional PAs. The median hospital stay was 2 days, with 34 patients (8%) readmitted within 30 days and 10 (3%) undergoing early reoperation. Disease recurrence or progression developed in 10% and was less likely in the case of gross total resection and apoplexy.

Conclusion: In the present, large, consecutive, mostly single-surgeon series, the patients experienced clinical improvement in most preoperative symptoms and had low rates of perioperative morbidity. We have demonstrated that direct EEA can be efficiently, safely, and successfully performed by a neurosurgical team.
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http://dx.doi.org/10.1016/j.wneu.2021.01.018DOI Listing
April 2021

5-ALA Enhanced Fluorescence-Guided Microscopic to Endoscopic Resection of Deep Frontal Subcortical Glioblastoma Multiforme.

World Neurosurg 2021 Apr 13;148:65. Epub 2021 Jan 13.

Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

Glioblastoma multiforme remains the most common adult primary brain tumor with a life expectancy of 15-18 months following best treatment strategies. Current paradigms incorporate maximal safe resection, chemotherapy, and radiation. Multiple variables correlate with increased survival; perhaps most notably are stepwise survival advantages following 78% and 98% extent of resection thresholds. 5-Aminolevulinic acid has become a vital tool in the intraoperative identification and differentiation of high-grade glioma as it provides a fluorescent effect capable of distinguishing tumor from normal brain tissue when observed under blue light, which to date has been used primarily via a microscopic light source. However, this effect is attenuated with increasing distance between the blue light source and the tumor, as in the case of deep seated resection cavities. We aimed to overcome this obstacle by using a blue light endoscope as the primary visualization platform, thereby advancing the light source directly into the resection cavity. We present the case of a 69-year-old man with a deep left frontal subcortical lesion proven to be glioblastoma multiforme on prior biopsy. He consented to undergo an interhemispheric "M2E" (microscopic-to-endoscopic) approach with subcortical motor mapping. Tumor fluorescence under blue light visualization was not appreciated by the operating microscope but was easily observed with the blue light endoscope. Tumor resection proceeded under direct blue light endoscopy with intermittent subcortical motor mapping until a threshold of 4 mA was reached. The patient had transient right arm and leg weakness. Postoperative magnetic resonance imaging confirmed >98% resection (Video 1).
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http://dx.doi.org/10.1016/j.wneu.2020.12.168DOI Listing
April 2021

Exoscopic to Endoscopic Channel-Based Trans-Sulcal Resection of a Third Ventricular Cavernous Malformation: Technical Case Illustration.

World Neurosurg 2021 Apr 13;148:66. Epub 2021 Jan 13.

Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

Cavernous malformations are angiographically occult vascular hamartomas without intervening neural tissue that represent an estimated 10% of central nervous system vascular pathologies. Management is often dictated by lesion location, intranidal versus extranidal hemorrhage, presenting symptoms, acuity of onset, and surgical accessibility. Deep-seated cavernous malformations are often adjacent to eloquent structures, including functional white matter tracts that must be accounted for during surgical planning and respected during resection of the cavernoma. Exoscopic-guided channel-based approaches can help minimize retraction of brain tissue while providing a navigated, direct path to the target lesion. We report a case of an 18-year-old man who presented with seizures and was found to have a hemorrhagic third ventricular cavernous malformation resulting in hydrocephalus. A right frontal trans-sulcal approach using an exoscope and channel-based retractor was performed and directed along the long axis of the lesion to minimize displacement of surrounding eloquent structures and manipulation of the fornix. An uneventful gross total resection was achieved and confirmed using an angled endoscope to inspect the cavity walls, the "exoscopic to endoscopic or E2E approach" (Video 1). The patient developed transient short-term memory dysfunction in the immediate postoperative period, likely due to retraction of the fornix, which dramatically improved with speech therapy and rehabilitation. The patient provided informed consent for surgery and video recording.
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http://dx.doi.org/10.1016/j.wneu.2021.01.007DOI Listing
April 2021

Stereotactic radiosurgery for treatment of radiation-induced meningiomas: a multiinstitutional study.

J Neurosurg 2021 Jan 1:1-9. Epub 2021 Jan 1.

1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.

Objective: Radiation-induced meningiomas (RIMs) are associated with aggressive clinical behavior. Stereotactic radiosurgery (SRS) is sometimes considered for selected RIMs. The authors investigated the effectiveness and safety of SRS for the management of RIMs.

Methods: From 12 institutions participating in the International Radiosurgery Research Foundation, the authors pooled patients who had prior cranial irradiation and were subsequently clinically diagnosed with WHO grade I meningiomas that were managed with SRS.

Results: Fifty-two patients underwent 60 SRS procedures for histologically confirmed or radiologically suspected WHO grade I RIMs. The median ages at initial cranial radiation therapy and SRS for RIM were 5.5 years and 39 years, respectively. The most common reasons for cranial radiation therapy were leukemia (21%) and medulloblastoma (17%). There were 39 multiple RIMs (35%), the mean target volume was 8.61 ± 7.80 cm3, and the median prescription dose was 14 Gy. The median imaging follow-up duration was 48 months (range 4-195 months). RIM progressed in 9 patients (17%) at a median duration of 30 months (range 3-45 months) after SRS. Progression-free survival at 5 years post-SRS was 83%. Treatment volume ≥ 5 cm3 predicted progression (HR 8.226, 95% CI 1.028-65.857, p = 0.047). Seven patients (14%) developed new neurological symptoms or experienced SRS-related complications or T2 signal change from 1 to 72 months after SRS.

Conclusions: SRS is associated with durable local control of RIMs in the majority of patients and has an acceptable safety profile. SRS can be considered for patients and tumors that are deemed suboptimal, poor surgical candidates, and those whose tumor again progresses after removal.
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http://dx.doi.org/10.3171/2020.7.JNS202064DOI Listing
January 2021

Commentary: Middle Cerebral Artery Aneurysm Clipping With Immersive 360° Virtual Reality Model: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 03;20(4):E315-E316

Department of Neurosurgery, University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1093/ons/opaa428DOI Listing
March 2021

Management of acute subdural hematoma in incarcerated patients.

Clin Neurol Neurosurg 2021 02 15;201:106441. Epub 2020 Dec 15.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Introduction: Incarcerated patients have been documented to have higher rates of mental illness, substance abuse disorders, trauma, and chronic illnesses compared to non-incarcerated populations. In this study, we evaluated the incidence of subdural hematoma (SDH) in incarcerated patients and compared the outcomes of these patients to those of non-incarcerated patients.

Methods: We conducted a retrospective cohort study of incarcerated patients admitted to a hospital with acute SDH using the Nationwide Readmissions Database between 2016-2017. Nearest-neighbor propensity score matching for demographics was implemented to identify non-incarcerated control patients admitted with SDH. Analysis used chi-squared testing, Mann-Whitney U testing, and generalized binomial regression modeling.

Results: A total of 962 incarcerated and non-incarcerated patients were identified at primary admission. No significant difference was found between the two cohorts with regards to rates of neurosurgical complications or readmissions. Incarcerated patients were found to receive a significantly lower number of procedures, including respiratory ventilation, intubation, central venous line placement, and imaging, during their primary admission (NPR = 2.7 ± 4.0) compared to non-incarcerated patients (NPR = 3.9 ± 4.9) (p = 0.00050), reduced length of stay (p = 0.0052), and reduced hospital costs (p = 0.00026) compared to non-incarcerated patients. Furthermore, female incarcerated patients with SDH had significantly worse outcomes compared to male patients with SDH, including higher rates of mortality (p = 0.0017) and 30-day readmission rates (p = 0.041).

Discussion: Our study suggests that incarcerated patients may receive significantly fewer diagnostic and supportive procedures while admitted for SDH and may be discharged sooner than non-incarcerated patients with SDH. In addition, outcomes following SDH within incarcerated patients may be significantly worse for females.
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http://dx.doi.org/10.1016/j.clineuro.2020.106441DOI Listing
February 2021

Commentary: Minimally Invasive Posterior Cervical Foraminotomy Using 3-Dimensional Total Navigation: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 01;20(2):E141-E142

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.

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http://dx.doi.org/10.1093/ons/opaa395DOI Listing
January 2021

Frailty Is Associated with In-Hospital Morbidity and Nonroutine Disposition in Brain Tumor Patients Undergoing Craniotomy.

World Neurosurg 2021 Feb 23;146:e1045-e1053. Epub 2020 Nov 23.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Objective: Frailty is associated with postoperative morbidity in multiple surgical disciplines. We evaluated the association between frailty and early postoperative outcomes for brain tumor patients using a national database.

Methods: We reviewed the Nationwide Readmissions Database from 2010 to 2014. International Classification of Diseases, ninth revision, codes were used to identify benign and malignant brain tumors treated with surgical resection. Pituitary tumors were excluded. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty indicator tool. Multivariable exact logistic regression was used to conduct analyses assessing the association between frailty and the outcome variables. Statistical significance was defined as P < 0.001.

Results: The criteria for frailty were met for 7209 of 87,835 patients (8.2%). After adjustment for patient and hospital factors, frailty was independently associated with in-hospital surgical complications (odds ratio [OR], 1.48; 95% confidence interval [CI] 1.37-1.59; P < 0.0001), mental status changes (OR, 1.9; 95% CI, 1.72-2.09; P < 0.0001), and pulmonary insufficiency (OR, 1.75; 95% CI, 1.55-1.96; P < 0.0001). Frailty was associated with an increased length of stay (incident rate ratio, 1.92; 95% CI, 1.87-1.98; P < 0.0001) and nonroutine disposition (OR, 1.84; 95% CI, 1.72-1.97; P < 0.0001). In-hospital mortality was greater for frail patients (2.2% vs. 1.4%; P < 0.0001), but the difference did not achieve significance on multivariate analysis. Frail patients were not more likely to be readmitted.

Conclusion: Frailty is associated with in-hospital complications and nonroutine disposition after craniotomy for benign and malignant brain tumors. Additional work is needed to identify prehabilitation or in-hospital strategies to improve the care and outcomes of these at-risk patients.
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http://dx.doi.org/10.1016/j.wneu.2020.11.083DOI Listing
February 2021

Automatic detection and segmentation of multiple brain metastases on magnetic resonance image using asymmetric UNet architecture.

Phys Med Biol 2021 01 13;66(1):015003. Epub 2021 Jan 13.

Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.

Detection of brain metastases is a paramount task in cancer management due both to the number of high-risk patients and the difficulty of achieving consistent detection. In this study, we aim to improve the accuracy of automated brain metastasis (BM) detection methods using a novel asymmetric UNet (asym-UNet) architecture. An end-to-end asymmetric 3D-UNet architecture, with two down-sampling arms and one up-sampling arm, was constructed to capture the imaging features. The two down-sampling arms were trained using two different kernels (3 × 3 × 3 and 1 × 1 × 3, respectively) with the kernel (1 × 1 × 3) dominating the learning. As a comparison, vanilla single 3D UNets were trained with different kernels and evaluated using the same datasets. Voxel-based Dice similarity coefficient (DSC), sensitivity (S ), precision (P ), BM-based sensitivity (S ), and false detection rate (F ) were used to evaluate model performance. Contrast-enhanced T1 MR images from 195 patients with a total of 1034 BMs were solicited from our institutional stereotactic radiosurgery database. The patient cohort was split into training (160 patients, 809 lesions), validation (20 patients, 136 lesions), and testing (15 patients, 89 lesions) datasets. The lesions in the testing dataset were further divided into two subgroups based on the diameters (small S = 1-10 mm, large L = 11-26 mm). In the testing dataset, there were 72 and 17 BMs in the S and L sub-groups, respectively. Among all trained networks, asym-UNet achieved the highest DSC of 0.84 and lowest F of 0.24. Although vanilla 3D-UNet with a single 1 × 1 × 3 kernel achieved the highest sensitivities for the S group, it resulted in the lowest precision and highest false detection rate. Asym-UNet was shown to balance sensitivity and false detection rate as well as keep the segmentation accuracy high. The novel asym-UNet segmentation network showed overall competitive segmentation performance and more pronounced improvement in hard-to-detect small BMs comparing to the vanilla single 3D UNet.
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http://dx.doi.org/10.1088/1361-6560/abca53DOI Listing
January 2021

Limited utility of 5-ALA optical fluorescence in endoscopic endonasal skull base surgery: a multicenter retrospective study.

J Neurosurg 2020 Oct 30:1-7. Epub 2020 Oct 30.

3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York.

Objective: Incomplete resection of skull base pathology may result in local tumor recurrence. This study investigates the utility of 5-aminolevulinic acid (5-ALA) fluorescence during endoscopic endonasal approaches (EEAs) to increase visibility of pathologic tissue.

Methods: This retrospective multicenter series comprises patients with planned resection of an anterior skull base lesion who received preoperative 5-ALA at two tertiary care centers. Diagnostic use of a blue light endoscope was performed during EEA for all cases. Demographic and tumor characteristics as well as fluorescence status, quality, and homogeneity were assessed for each skull base pathology.

Results: Twenty-eight skull base pathologies underwent blue-light EEA with preoperative 5-ALA, including 15 pituitary adenomas (54%), 4 meningiomas (14%), 3 craniopharyngiomas (11%), 2 Rathke's cleft cysts (7%), as well as plasmacytoma, esthesioneuroblastoma, and sinonasal squamous cell carcinoma. Of these, 6 (21%) of 28 showed invasive growth into surrounding structures such as dura, bone, or compartments of the cavernous sinus. Tumor fluorescence was detected in 2 cases (7%), with strong fluorescence in 1 tuberculum sellae meningioma and vague fluorescence in 1 pituicytoma. In all other cases fluorescence was absent. Faint fluorescence of the normal pituitary gland was seen in 1 (7%) of 15 cases. A comparison between the particular tumor entities as well as a correlation between invasiveness, WHO grade, Ki-67, and positive fluorescence did not show any significant association.

Conclusions: With the possible exception of meningiomas, 5-ALA fluorescence has limited utility in the majority of endonasal skull base surgeries, although other pathology may be worth investigating.
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http://dx.doi.org/10.3171/2020.5.JNS201171DOI Listing
October 2020