Publications by authors named "Ignacio Jusue-Torres"

57 Publications

Dandy's hemispherectomies: historical vignette.

J Neurosurg 2021 May 14:1-7. Epub 2021 May 14.

To better understand Walter Dandy's intentions and the historical context of his work on hemispherectomy, the authors reviewed his original 1928 publication. Gliomas were considered incurable at that time. Presuming that the loss of motor function denoted a lack of useful tissue in that hemisphere, he pioneered radical removal of the involved cerebral hemisphere. Of the 5 patients operated on by Dandy, 1 died within 48 hours of hemorrhage because of a displaced vascular clip; 1 died of pneumonia in 2 weeks; 2 died of tumor recurrence, at 3 months and 3.5 years, respectively; and a fifth patient was lost to follow-up beyond the 2nd postoperative week. The authors queried the Thomson Reuters Web of Science and Scopus. A total of 88 papers fulfilled inclusion criteria. Half of these papers (44/88) were published after 2012. Only 11% of papers (10/88) quoted Dandy's paper accurately; half of them were published before 1997. Most publications (76% [67/88]) quoted Dandy incorrectly, all of them from 1997 and later. In the remaining 11 papers (13%), the accuracy of the quotes was unclear. The authors found a trend toward more accurate citation in earlier papers. Critically reviewing Dandy's report, with an understanding of the historical context, allows a better understanding of his intentions and the value of his contribution.
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http://dx.doi.org/10.3171/2020.9.JNS202824DOI Listing
May 2021

Effectiveness of a Standardized External Ventricular Drain Placement Protocol for Infection Control.

World Neurosurg 2021 May 4. Epub 2021 May 4.

Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA. Electronic address:

Introduction: Placement of an external ventricular drain (EVD) is a common procedure routinely completed at bedside by neurosurgical residents. A standardized protocol for placement and maintenance of an EVD is potentially useful.

Methods: This single-institution retrospective review analyzed all patients who underwent placement of an EVD over a 5-year span using a standardized protocol.

Results: A total of 428 EVDs in 381 patients were placed as per this protocol. Overall compliance with the practice protocol was 98.7%. Overall, our infection rate was 1.86% (8 external ventricular drain-related infection [ERIs] over 428 EVDs). There was no difference in age for the ERI cases (median 55, range (50.5-60.5), compared with the non-ERI cases (median of 53, range [38-65]) (P = 0.512). Indications for placement of EVD were hemorrhage (51.9%, n = 198), tumor (16.2%, n = 62), trauma (12.8%, n = 49), hydrocephalus (11.5%, n = 44), cerebellar stroke (2.8%, n = 11), infection (3.1%, n = 12), unknown (1.3%, n = 5). Most EVDs (77.6%, n = 296) were placed bedside by second-year residents (median PGY level 2, interquartile range 1-2.75). Computed tomography confirmed placement in the ipsilateral frontal horn in 72% (n = 277) of EVDs. EVD-related complications were noted in 8.3% of EVDs (n = 32, with 8 infections and 24 tract hemorrhages). The median EVD duration was 10 days; duration of EVD had no statistically significant impact on the risk of an ERI (P = 1). Only replacement of an EVD was associated with an increased risk of infection.

Conclusions: Adherence to a standard EVD placement protocol is useful in maintaining a low risk of ERI regardless of the duration of catheter utilization. Replacement of the catheter through the same access hole as the original catheter is associated with an increased risk of ERI.
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http://dx.doi.org/10.1016/j.wneu.2021.04.113DOI Listing
May 2021

Long-Term Outcomes of Pituitary Gland Preservation in Pituitary Macroadenoma Apoplexy: Case Series and Review of the Literature.

J Neurol Surg B Skull Base 2021 Apr 11;82(2):182-188. Epub 2019 Nov 11.

Department of Neurological Surgery, Loyola University Stritch School of Medicine, Maywood, Illinois, United States.

 For patients presenting with neurological changes from pituitary tumor apoplexy, urgent surgical intervention is commonly performed for diagnosis, tumor resection, and optic apparatus decompression. Although identification and preservation of the pituitary gland during the time of surgery can be challenging, it may lead to improve endocrine outcomes.  A retrospective case series of all patients with macroadenomas presenting with apoplexy at Loyola University Medical Center from 2016 to 2018 was studied. Demographic, radiographic, and intraoperative characteristics were collected including age, gender, comorbidities, presenting symptoms, preoperative size of pituitary adenoma, Knosp's grade, Hardy's grade, identification and/or preservation of the gland, pre- and postoperative hormonal levels, intraoperative and/or postoperative complications, and follow-up time.  A total of 68 patients underwent endoscopic endonasal surgery for resection of a macroadenoma. Among them, seven (10.2%) presented with apoplexy; five patients were male and two were female and presenting symptoms and signs included headache (100%), endocrinopathies (57%), visual acuity deficit (71%), visual field deficit (71%), and oculomotor palsy (57%). A gross-total resection rate was achieved in 86% of patients. Among them, 71% of patients obtained complete symptomatic neurological improvement. A statistically significant difference between gender and endocrine function was found, as no females and all males required some form of postoperative hormonal supplementation (  = 0.047)  Endoscopic endonasal resection of macroadenomas with sparing of the pituitary gland in the setting of apoplexy is safe and effective. Preservation of the normal gland led to no posterior pituitary dysfunction, and a statistically significant difference between gender and postoperative endocrinopathy was identified. Further studies with larger samples sizes are warranted.
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http://dx.doi.org/10.1055/s-0039-3400220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987398PMC
April 2021

Activation of 4-1BBL+ B cells with CD40 agonism and IFNγ elicits potent immunity against glioblastoma.

J Exp Med 2021 Jan;218(1)

Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.

Immunotherapy has revolutionized the treatment of many tumors. However, most glioblastoma (GBM) patients have not, so far, benefited from such successes. With the goal of exploring ways to boost anti-GBM immunity, we developed a B cell-based vaccine (BVax) that consists of 4-1BBL+ B cells activated with CD40 agonism and IFNγ stimulation. BVax migrates to key secondary lymphoid organs and is proficient at antigen cross-presentation, which promotes both the survival and the functionality of CD8+ T cells. A combination of radiation, BVax, and PD-L1 blockade conferred tumor eradication in 80% of treated tumor-bearing animals. This treatment elicited immunological memory that prevented the growth of new tumors upon subsequent reinjection in cured mice. GBM patient-derived BVax was successful in activating autologous CD8+ T cells; these T cells showed a strong ability to kill autologous glioma cells. Our study provides an efficient alternative to current immunotherapeutic approaches that can be readily translated to the clinic.
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http://dx.doi.org/10.1084/jem.20200913DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527974PMC
January 2021

Survival benefit of concomitant chemoradiation in adult supratentorial primary glioblastoma. A propensity score weighted population-based analysis.

J Neurosurg Sci 2020 Sep 24. Epub 2020 Sep 24.

Department of Neurological Surgery, Loyola University Stritch School of Medicine, Maywood, IL, USA.

Background: This population study aims to assess the impact of the implementation of the original Stupp protocol on overall survival in patients with new-diagnosed supratentorial primary GBM.

Methods: The Surveillance, Epidemiology, and End Results (SEER) database was used to study the survival of histologically confirmed adult supratentorial GBM patients diagnosed between 1998 and 2016. Kaplan-Meier, and a univariate and propensity-score weighted multivariate Cox proportional hazard model adjusted for age at diagnosis, sex, race, marital status and extent of resection was used to assess the survival of patients prior to implementation of the Stupp protocol in 2005 (Pre-Stupp) and following implementation of the Stupp Protocol until 2016 (Post Stupp).

Results: 6,390 patients satisfied inclusion exclusion criteria. Median survival times were 13 months for the Pre-Stupp and 15 months for Post-Stupp groups (p<0.001). The 1-,2-, 5- and 10- year survival rates for the Pre-Stupp group were 51, 18, 5 and 2% respectively compared to 59, 27, 8 and 4% on the Post-Stupp group. Propensity-score weighted analysis showed a lower mortality risk for patients who underwent concomitant chemoradiation during the Post-Stupp era [HR 0.77, 95% CI 0.62-0.94]. There was a 42 percent relative reduction in the risk of death for patients treated during the Post-Stupp era.

Conclusions: This population-based propensity-score study with long-term follow-up suggests that the implementation of the Stupp protocol in 2005 had a positive impact on the survival of patients with supratentorial GBM. This "real-world" analysis validates the results of the original randomized control trial on which this protocol is based.
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http://dx.doi.org/10.23736/S0390-5616.20.05023-7DOI Listing
September 2020

Detection of Promoter DNA Methylation in Urine and Plasma Aids the Detection of Non-Small Cell Lung Cancer.

Clin Cancer Res 2020 08 19;26(16):4339-4348. Epub 2020 May 19.

Cancer Center, University of Illinois at Chicago, Chicago, Illinois.

Purpose: Low-dose CT screening can reduce lung cancer-related mortality. However, CT screening has an FDR of nearly 96%. We sought to assess whether urine samples can be a source for DNA methylation-based detection of non-small cell lung cancer (NSCLC).

Experimental Design: This nested case-control study of subjects with suspicious nodules on CT imaging obtained plasma and urine samples preoperatively. Cases ( = 74) had pathologic confirmation of NSCLC. Controls ( = 27) had a noncancer diagnosis. We detected promoter methylation in plasma and urine samples using methylation on beads and quantitative methylation-specific real-time PCR for cancer-specific genes (, and ).

Results: DNA methylation at cancer-specific loci was detected in both plasma and urine, and was more frequent in patients with cancer compared with controls for all six genes in plasma and in , and in urine. Univariate and multivariate logistic regression analysis showed that methylation detection in each one of six genes in plasma and , and in urine were significantly associated with the diagnosis of NSCLC, independent of age, race, and smoking pack-years. When methylation was detected for three or more genes in both plasma and urine, the sensitivity and specificity for lung cancer diagnosis were 73% and 92%, respectively.

Conclusions: DNA methylation-based biomarkers in plasma and urine could be useful as an adjunct to CT screening to guide decision-making regarding further invasive procedures in patients with pulmonary nodules.
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http://dx.doi.org/10.1158/1078-0432.CCR-19-2896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442601PMC
August 2020

The 100 Most Cited Papers About Cancer Epigenetics.

Cureus 2020 Apr 10;12(4):e7623. Epub 2020 Apr 10.

Surgery, University of Illinois at Chicago, Chicago, USA.

Introduction Although bibliometric analyses have been performed in the past on cancer and genomics, little is known about the most frequently cited articles specifically related to cancer epigenetics. Therefore, the purpose of this study is to use citation count to identify those papers in the scientific literature that have made key contributions in the field of cancer epigenetics and identify key driving forces behind future investigations. Materials and methods The Thomas Reuters Web of Science services was queried for the years 1980-2018 without language restrictions. Articles were sorted in descending order of the number of times they were cited in the Web of Science database by other studies, and all titles and abstracts were screened to identify the research areas of the top 100 articles. The number of citations per year was calculated. Results We identified the 100 most-cited articles on cancer epigenetics, which collectively had been cited 147,083 times at the time of this writing. The top-cited article was cited 7,124 times, with an average of 375 citations per year since publication. In the period 1980-2018, the most prolific years were the years 2006 and 2010, producing nine articles, respectively. Twenty-eight unique journals contributed to the 100 articles, with the Nature journal contributing most of the articles (n=22). The most common country of article origin was the United States of America (n=78), followed by Germany (n=4), Switzerland (n=4), Japan (n=3), Spain (n=2), and United Kingdom (n=2). Conclusions In this study, the 100 most-cited articles in cancer epigenetics were examined, and the contributions from various authors, specialties, and countries were identified. Cancer epigenetics is a rapidly growing scientific field impacting translational research in cancer screening, diagnosis, classification, prognosis, and targeted treatments. Recognition of important historical contributions to this field may guide future investigations.
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http://dx.doi.org/10.7759/cureus.7623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213660PMC
April 2020

Surgical clipping of a non-ruptured ophthalmic aneurysm through an extradural micropterional keyhole approach.

Acta Neurochir (Wien) 2020 04 17;162(4):917-921. Epub 2020 Feb 17.

Department of Skull base and Cerebrovascular Surgery, Institute of Neurosurgery Asenjo, Santiago, Chile.

Background: Clipping continues to be one of the treatment strategies for ophthalmic artery aneurysms not amenable for stenting or coiling, or when long-term treatment durability is a concern. However, crescent development of endovascular techniques demands minimal invasiveness in the transcranial approaches while ensuring satisfactory results.

Methods: We describe an extradural micropterional keyhole approach (eMKA) to the paraclinoid region and highlight the key anatomical elements of this surgical approach.

Conclusion: The eMKA is a minimally invasive approach that provides access to the paraclinoid region using an extradural corridor. Therefore, it is suitable for clipping of ophthalmic artery aneurysms and other paraclinoid aneurysms.
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http://dx.doi.org/10.1007/s00701-020-04261-5DOI Listing
April 2020

Value of K -67 Labeling Index in Predicting Recurrence of WHO Grade I Cranial Base Meningiomas.

J Neurol Surg B Skull Base 2019 Jun 6;80(3):287-294. Epub 2018 Sep 6.

Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, United States.

 Assess impact of K -67 labeling index (LI; K -67 LI) on risk of recurrence or progression of WHO grade I meningiomas.  Retrospective study of adult patients who underwent resection of cranial base meningioma between 2004 and 2016.  272 patients fulfilled criteria for inclusion in the study. Average age was 61.8 years; 196 (72%) were females. Simpson's grade 1 resection was noted in 77 patients (32%), grade 2 in 39 (16%), grade 3 in 36 (15%), and grade 4 in 88 (37%). The K -67 LI was low (1-4%) in 214 (78.7%), intermediate (5-9%) in 44 (16.2%), and high (>10%) in 14 (5.2%). Median follow-up was 39 months (IQR: 16-71 months); 221 (87.1%) tumors remained stable or did not recur, 19 (7.4%) recurred, and 14 (5.5%) progressed. Compared with tumors with low K -67 LI, those with intermediate K -67 LI had 2.47 times (2.47 [1.09-5.59],  = 0.03), and those with high K -67 LI had 3.38 times (3.38 [1.16-9.89],  = 0.03) higher risk of recurrence or progression. Tumors with K -67 LI > 4% had a shorter time to recurrence or progression (  = 0.01). Recurrence or progression-free survival rates at 3, 5, and 10 years for tumors with low K -67 LI were 95%, 89%, and 75%, respectively; tumors with intermediate K -67 LI, 87%, 69%, and 52%, respectively; tumors with high K -67 LI, 78%, 49%, and 49%, respectively.  Following surgical resection of a WHO grade I cranial base meningioma, K -67 LI > 4% may predict an increased risk of recurrence or progression of residual tumor.
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http://dx.doi.org/10.1055/s-0038-1669387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534743PMC
June 2019

Aqueductal Cerebrospinal Fluid Stroke Volume Flow in a Rodent Model of Chronic Communicating Hydrocephalus: Establishing a Homogeneous Study Population for Cerebrospinal Fluid Dynamics Exploration.

World Neurosurg 2019 Aug 21;128:e1118-e1125. Epub 2019 May 21.

Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia. Electronic address:

Background: Idiopathic normal pressure hydrocephalus (iNPH) is a cause of dementia that can be reversed when treated timely with cerebrospinal fluid (CSF) diversion. Understanding CSF dynamics throughout the development of hydrocephalus is crucial to identify prognostic markers to estimate benefit/risk to shunts.

Objective: To explore the cerebral aqueduct CSF flow dynamics with phase-contrast magnetic resonance imaging (MRI) in a novel rodent model of adult chronic communicating hydrocephalus.

Methods: Kaolin was injected into the subarachnoid space at the convexities in Sprague-Dawley adult rats. 11.7-T Bruker MRI was used to acquire T2-weighted images for anatomic identification and phase-contrast MRI at the cerebral aqueduct. Aqueductal stroke volume (ASV) results were compared with the ventricular volume (VV) at 15, 60, 90, and 120 days.

Results: Significant ventricular enlargement was found in kaolin-injected animals at all times (P < 0.001). ASV differed between cases and controls/shams at every time point (P = 0.004, 0.001, 0.001, and <0.001 at 15, 60, 90, and 120 days, respectively). After correlation between the ASV and the VV, there was a significant correlation at 15 (P = 0.015), 60 (P = 0.001), 90 (P < 0.001), and 120 days. Moreover, there was a significant positive correlation between the VV expansion and the aqueductal CSF stroke between 15 and 60 days.

Conclusions: An initial active phase of rapid ventricular enlargement shows a strong correlation between the expansion of the VV and the increment in the ASV during the first 60 days, followed by a second phase with less ventricular enlargement and heterogeneous behavior in the ASV. Further correlation with complementary data from intracranial pressure and histologic/microstructural brain parenchyma assessments are needed to better understand the ASV variations after 60 days.
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http://dx.doi.org/10.1016/j.wneu.2019.05.093DOI Listing
August 2019

Health Care Expenditures of Medicare Beneficiaries with Normal Pressure Hydrocephalus.

World Neurosurg 2019 Jul 28;127:e548-e555. Epub 2019 Mar 28.

Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA. Electronic address:

Background: Normal pressure hydrocephalus (NPH) is an underdiagnosed and undertreated condition affecting the elderly population and with costs associated with its surgical management reported to be less than those associated with conservative management.

Objective: To determine if the rate of diagnosis of NPH has improved over the last decade, the rate of treatment has increased, and if surgical treatment costs and socioeconomic factors related to receipt of treatment have changed over time compared with conservative therapy.

Methods: A retrospective study based on data from a nationally representative random sample of 2,378,637 Medicare beneficiaries (2006-2010) was performed. Shunt surgery, shunt revision, replacement, and removal were analyzed as independent variables.

Results: A total of 2321 patients with NPH were included, with 580 (24.99%) receiving a first shunt procedure. The adjusted effect of the procedure is that total 5-year expenditures are $11,676 more per patient (P < 0.001) than expenditures associated with nonsurgical management. Shunt revision ($22,715, P < 0.01) and/or replacement ($46,607, P < 0.001) add significantly to 5-year expenditures. Socioeconomic factors including African American race (P = 0.006); age 75-79 years (P = 0.024), 80-84 years (P < 0.001), and ≥85 years (P < 0.001); and Medicaid (P < 0.001) have significant negative associations with shunt surgery.

Conclusions: There was a 1.66-fold increase in the rate of diagnosis of NPH, from 0.12% in 1999 to 0.2% in 2008. The total costs per surgical patient rose by approximately 145% to 160% comparing 2001 and 2010. This increase was mainly due to hospital (by 167% to 168%) and home health costs (by 118% to 148%). Providing appropriate care across the socioeconomic spectrum warrants further study and requires identifying the factors that limit access to care.
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http://dx.doi.org/10.1016/j.wneu.2019.03.201DOI Listing
July 2019

In Reply to the Letter to the Editor "Craniopharyngioma: 10 Selected Works Which Provide Comprehensive and Valuable Insight into These Complex Tumors".

World Neurosurg 2019 02;122:713-714

Department of Neurological Surgery, Loyola University Stritch School of Medicine, Maywood, Illinois, USA; Department of Otolaryngology, Loyola University Stritch School of Medicine, Maywood, Illinois, USA; Department of Neurological Surgery, Edward Hines, Jr. VA Hospital, Hines, Illinois, USA.

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http://dx.doi.org/10.1016/j.wneu.2018.10.223DOI Listing
February 2019

Ventricular Volume Dynamics During the Development of Adult Chronic Communicating Hydrocephalus in a Rodent Model.

World Neurosurg 2018 Dec 11;120:e1120-e1127. Epub 2018 Sep 11.

Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia. Electronic address:

Introduction: The pathophysiology of normal-pressure hydrocephalus and the correlation with its symptomatology is not well understood.

Objective: To monitor and evaluate the enlargement patterns of the ventricular system for each ventricle and its correlation with the presenting symptoms.

Methods: Bilateral kaolin injection into the subarachnoid space overlying the cranial convexities was done in 18 adult rats. Magnetic resonance imaging was performed on an 11.7-T scanner 15, 60, 90, and 120 days after injection. Volumes of the ventricular system were measured for each ventricle and correlated with biweekly behavioral findings.

Results: There was a progressive increase in the ventricular volume for the lateral ventricles since day 15 in the kaolin-injected animals. There was a nonsignificant trend in volume growth for the third ventricle, but its enlargement was synchronous with the lateral ventricles. No significant change for the fourth ventricle. No symptoms were detected in the first 60 days. Association was found between the ventricular volume and locomotor changes. In addition, the odds of locomotor symptoms increased by 3% for every additional cubic millimeter of volume in the left (P < 0.001) and right (P = 0.023) ventricles, and for the total magnetic resonance imaging volume by 1% (P = 0.013).

Conclusions: Expansion of the lateral ventricles maintained similar proportions over time, accompanied by a synchronous third ventricular expansion with less proportion and a nonsignificant fourth enlargement. Lateral ventricles enlarged most in those animals that were to develop late locomotor deterioration. Further research using this animal model combined with different radiologic imaging techniques, such as diffusion tensor imaging and perfusion studies, is recommended.
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http://dx.doi.org/10.1016/j.wneu.2018.08.241DOI Listing
December 2018

The 100 Most-Cited Reports About Craniopharyngioma.

World Neurosurg 2018 Nov 9;119:e910-e921. Epub 2018 Aug 9.

Department of Neurological Surgery, Loyola University Stritch School of Medicine, Maywood, Illinois, USA; Department of Otolaryngology-Head and Neck Surgery, Loyola University Stritch School of Medicine, Maywood, Illinois, USA; Section of Neurological Surgery, Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois, USA.

Objective: Our objective was to identify the 100 most-cited research reports on craniopharyngiomas.

Methods: The Thomson Reuters Web of Science service was queried for the years 1900 to 2017 without language restrictions. The articles were sorted in descending order of the number of times they had been cited by other studies, and all titles and abstracts were screened to identify the research areas of the top 100 reports. The number of citations per year was calculated.

Results: We identified the 100 most-cited articles on craniopharyngioma, which, collectively, had been cited 20,994 times at the time of our report. The top cited report had been cited 718 times, with an average of 144 citations annually since publication. The oldest article had been published in 1969 and the most recent in 2013; the most prolific decade was the 2000s, with 38 of the included articles published during that period. Thirty-two unique journals contributed to the 100 articles, with the Journal of Neurosurgery contributing most of the articles (n = 31). The most common country of article origin was the United States (n = 49), followed by United Kingdom (n = 12), Germany (n = 10), and Italy (n = 6).

Conclusions: The present study identified the 100 most-cited research articles in craniopharyngioma. These results highlight the multidisciplinary and multimodal nature of craniopharyngioma management. Recognition of important historical contributions to this field could guide future investigations.
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http://dx.doi.org/10.1016/j.wneu.2018.08.004DOI Listing
November 2018

The Quest for Predicting Sustained Shunt Response in Normal-Pressure Hydrocephalus: An Analysis of the Callosal Angle's Utility.

World Neurosurg 2018 Jul 1;115:e717-e722. Epub 2018 May 1.

Department of Neurological Surgery, Loyola University School of Medicine, Maywood, Illinois, USA.

Background: Diagnosing normal-pressure hydrocephalus (NPH) and selecting patients who will experience a sustained benefit from fluid diversion surgery remains challenging. This study seeks to evaluate the association between the callosal angle (CA) and the long-term postoperative response to ventriculoperitoneal shunt surgery in a different subgroup population than previously studied to assess its generalizability.

Methods: We studied 72 patients with idiopathic NPH who underwent ventriculoperitoneal shunt surgery and had at least 18 months of follow-up between 2000 and 2016. We recorded their pre- and postoperative symptoms according to the NPH Eide scale and their comorbidities with the Kiefer index. Their CA, as well as Evans' Index, ventricular height, and transependymal signal were measured. Multivariable statistical models were used to determine which factors were associated with postoperative improvement while we controlled for the presence of the NPH triad.

Results: Fifty-nine patients (82%) demonstrated a successful response to surgery at their first postoperative follow-up. However, this declined to 54 patients (75%) at 1 year and 45 (62.5%) patients at their last follow-up. When we controlled for the presence of the triad of symptoms, the CA significantly predicted a good, sustained response to surgery; for every degree decrease in the CA, a patient is 4% more likely to experience benefit from surgery.

Conclusions: The CA is a useful preoperative prognostic tool for predicting which patients will experience a sustained benefit from surgery. Further studies are required to clarify this disease in the context of old age, comorbidity, and possible concomitant neurodegenerative diseases.
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http://dx.doi.org/10.1016/j.wneu.2018.04.150DOI Listing
July 2018

Lung cancer recurrence epigenetic liquid biopsy.

J Thorac Dis 2018 Jan;10(1):4-6

Department of Neurological Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL, USA.

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http://dx.doi.org/10.21037/jtd.2017.11.124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5863116PMC
January 2018

Radiation-induced meningiomas: A case-control study at single center institution.

J Neurol Sci 2018 04 21;387:205-209. Epub 2018 Feb 21.

Department of Neurosurgery, University of Miami, 1095 NW 14th Terrace, Room 2-06, Miami, FL 33136, USA. Electronic address:

Background: Our understanding of radiation induced meningiomas (RIM) is limited. It has been suggested that RIM harbor more aggressive cellular pathology and must be observed vigilantly. However, the actual recurrence rates of RIM compared to the sporadic meningiomas has yet to be defined.

Objective: We employ a single center case-control study to retrospectively assess recurrence rates between RIM (n = 12) and sporadic meningiomas (n = 118).

Methods: The criteria for the RIM group included the following: 1) History of intracranial clinical-dose radiation 2) Initial pathology other than meningioma, 3) Radiation administered greater than 5 years prior to meningioma onset. Recurrence rates, extent of resection and outcomes were analyzed.

Results: There was a significant difference in recurrence rates between the RIM group and sporadic meningioma: 50% vs. 5% respectively, p = 0.004. There was no significant difference in race, preoperative tumor volume, extent of resection, Ki67, or age between the two groups. Multivariate analysis demonstrated that size (OR 0.95 95%CI (0.92-0.99)), extent of resection (OR 1.08 95%CI (1.01-1.14)), WHO grade (OR 160.24 95% CI (6.32-74509)) and history of previous radiation (OR 1.28 95%CI (1.01-1.62)) were independent risk factors for recurrence. RIM patients had significantly higher proportion of atypical or malignant histology compared to sporadic patients (p < 0.0001).

Conclusion: RIM patients may have a higher predisposition for tumor recurrence than patients with sporadic RIM. The use of Ki67 indices may help identify patients with a higher risk of tumor recurrence. Prospective studies focusing on newly diagnosed patients with RIM may help identify an optimal surveillance and treatment plan.
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http://dx.doi.org/10.1016/j.jns.2018.02.033DOI Listing
April 2018

Long-term Treatment Response and Patient Outcomes for Vestibular Schwannoma Patients Treated with Hypofractionated Stereotactic Radiotherapy.

Front Oncol 2017 4;7:200. Epub 2017 Sep 4.

Johns Hopkins University, Baltimore, MD, United States.

Purpose: The aim of this study is to evaluate long-term treatment outcome and toxicities among vestibular schwannoma (VS) patients treated with hypofractionated stereotactic radiotherapy (HSRT).

Methods: 383 patients with unilateral VS treated with HSRT (25 Gy, five fractions) between 1995 and 2007 were retrospectively reviewed. Treatment failure was defined as requiring salvage microsurgery. Posttreatment new/progressive clinical symptoms or increases in baseline tumor volume (BTV) due to treatment effect or progression were noted. Symptom outcomes were reported as baseline and posttreatment ± improvement, respectively. Symptoms were grouped by cranial nerve (CN) VII or CNVIII. Audiometry was assessed baseline and posttreatment hearing. Patients were grouped as having greater than serviceable hearing [Gardner Robertson (GR) score 1-2] or less than non-serviceable hearing (GR score 3-5) by audiometry.

Results: Median follow-up was 72.0 months. Nine (2.3%) experienced treatment failure. At last follow-up, 74 (19.3%) had new/progressive symptoms and were categorized as radiologic non-responders, whereas 300 (78.3%) had no tumor progression and were grouped as radiologic responders. Average pretreatment BTV for treatment failures, radiologic non-responders, and radiologic responders was 2.11, 0.44, and 1.87 cm, respectively. Pretreatment CNVII and CNVIII symptoms were present in 9.4 and 93.4% of patients, respectively. Eight (24%) with pre-HSRT CNVII and 37 (10%) with pre-HSRT CNVIII symptoms recovered CN function post-HSRT. Thirty-five (9%) and 36 (9.4%) experienced new CNVII and CNVIII deficit, respectively, after HSRT. Of these, 20 (57%) and 18 (50%) recovered CNVII and CNVIII function, respectively, after HSRT. Evaluable audiograms were available in 199 patients. At baseline and at last follow-up, 65.8 and 36.2% had serviceable hearing, respectively. Fifty-one percent had preservation of serviceable hearing at last follow-up.

Conclusion: Treatment of VS with HSRT is effective with treatment success in 97.7% and an acceptable toxicity profile. Less than one-third of patients experience any new CNVII or CNVIII deficit posttreatment. Greater than 50% of patients with serviceable hearing at baseline maintained hearing function. Improved methods to differentiate treatment effect and tumor progression are needed.
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http://dx.doi.org/10.3389/fonc.2017.00200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5591320PMC
September 2017

Visual Deficit From Laser Interstitial Thermal Therapy for Temporal Lobe Epilepsy: Anatomical Considerations.

Oper Neurosurg (Hagerstown) 2017 10;13(5):627-633

Department of Neurological Surgery, University of Miami, Miami, Florida.

Background: Laser interstitial thermal therapy (LITT) is quickly emerging as an effective surgical therapy for temporal lobe epilepsy (TLE). One of the most frequent complications of the procedure is postoperative visual field cuts, but the physiopathology of these deficits is unknown.

Objective: To evaluate potential causes of visual deficits after LITT for TLE in an attempt to minimize this complication.

Methods: This retrospective chart review compares the case of a 24-year-old male who developed homonymous hemianopsia following LITT for TLE to 17 prior patients who underwent the procedure and suffered no visual deficit. We examined both features of the surgical approach (trajectory, laser energy, ablation size) and of preoperative surgical anatomy, derived from volumetric tracings of mesiotemporal structures.

Results: For the patient with postoperative homonymous hemianopsia imaging suggested inadvertent ablation of the lateral geniculate nucleus, although the laser was positioned entirely within the hippocampus. This patient's laser trajectory, ablation number, energy delivered, and ablation size were not significantly different from the prior patients. However, the subject with the visual deficit did have significantly smaller choroidal fissure cerebrospinal fluid volume.

Conclusion: Visual deficits are the most common complication of LITT for mesiotemporal epilepsy and patients at most risk may have small cerebrospinal fluid volume in the choroidal fissure, allowing heat to spread from the hippocampal body to the lateral geniculate nucleus. When such anatomy is identified on preoperative magnetic resonance imaging, we recommend lowering laser trajectory, decreasing ablation power through the hippocampal body, and using temperature safety markers at the lower thalamic border.
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http://dx.doi.org/10.1093/ons/opx029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606145PMC
October 2017

Ultrasound for the assessment of distal shunt malfunction in adults with internal ventricular shunts.

J Clin Neurosci 2017 Nov 6;45:282-287. Epub 2017 Sep 6.

Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA. Electronic address:

Shunts that are used for the treatment of hydrocephalus have a propensity towards malfunction, however, diagnosing a shunt malfunction can sometimes be a challenge. The purpose of this study was to investigate whether ultrasound technology can be safely and effectively used to assess for distal shunt malfunction. This was a prospective cohort study at a single institution. Eighteen adult patients that received a radionuclide shunt patency study also underwent an ultrasound shunt patency study. Ultrasound with Doppler technology was used to visualize flow through the shunt tubing following manual compression of the shunt reservoir. A peak flow speed was recorded and the results were compared to the results of the radionuclide shunt patency study. A Receiver Operating Characteristic (ROC) curve comparing the ultrasound to the radionuclide shunt patency study was generated, revealing an Area Under the Curve (AUC) of 0.95 (95% CI: 0.84-1.00). The ultrasound test performed maximally with a cutoff speed of ≤10cm/s as the criteria for malfunction, with a sensitivity of 100.00%, specificity of 90.91%, accuracy of 94.44%, positive likelihood ratio of 11.000 and negative likelihood ratio of 0.000 using the radionuclide study results as criteria for comparison. Overall, ultrasound has the potential to be a safe, quick, available and cost-effective screening test for patients with suspected distal shunt malfunction. The high sensitivity of the test makes it an attractive option for use as a screening method that could potentially reduce the number of cases requiring radionuclide shunt patency study.
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http://dx.doi.org/10.1016/j.jocn.2017.08.026DOI Listing
November 2017

Alzheimer's disease pathology and shunt surgery outcome in normal pressure hydrocephalus.

PLoS One 2017 7;12(8):e0182288. Epub 2017 Aug 7.

Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America.

We aimed to determine whether presence of AD neuropathology predicted cognitive, gait and balance measures in patients with idiopathic normal pressure hydrocephalus (iNPH) after shunt surgery. This is a prospective study of gait and balance measured by Timed Up and Go (TUG) and Tinetti tests, and cognitive function measured by Mini Mental Status Exam (MMSE), before and after shunt surgery in participants 65 years and older with iNPH at the Johns Hopkins University. Random effects models were used and adjusted for confounders. 88 participants were included in the analysis with a median (IQR) time of 104 (57-213) days between surgery and follow-up. 23 (25%) participants had neuritic plaques present (NP+) and were significantly older [76.4 (6.0) years], but were otherwise similar in all demographics and outcome measures, when compared to the group without neuritic plaques (NP-). NP- and NP+ participants equally improved on measures of TUG (β = -3.27, 95% CI -6.24, -0.30, p = 0.03; β = -2.37, 95% CI -3.90, -0.86, p = 0.02, respectively), Tinetti-total (β = 1.95, 95% CI 1.11, 2.78, p<0.001; β = 1.72, 95% CI 0.90, 2.53, p<0.001, respectively), -balance (β = 0.81, 95% CI 0.23, 1.38, p = 0.006; β = 0.87, 95% CI 0.40, 1.34, p<0.001, respectively) and -gait (β = 1.03, 95% CI 0.61, 1.45, p<0.001; β = 0.84, 95% CI 0.16, 1.53, p = 0.02, respectively), while neither NP- nor NP+ showed significant improvement on MMSE (β = 0.10, 95% CI -0.27, 0.46, p = 0.61, β = 0.41, 95% CI -0.27, 1.09, p = 0.24, respectively). In summary, 26% of participants with iNPH had coexisting AD pathology, which does not significantly influence the clinical response to shunt surgery.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0182288PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5546572PMC
October 2017

Pathogens and glioma: a history of unexpected discoveries ushering in novel therapy.

J Neurosurg 2018 04 9;128(4):1139-1146. Epub 2017 Jun 9.

2Cell Biology, and.

In the late 19th century, Dr. William B. Coley introduced the theory that infections may aid in the treatment of malignancy. With the creation of Coley's toxin, reports of remission during viral illnesses for systemic malignancies soon emerged. A few decades after this initial discovery, Austrian physicians performed intravascular injections of Clostridium to induce oncolysis in patients with glioblastoma. Since then, suggestions between improved survival and infectious processes have been reported in several patients with glioma, which ultimately marshaled the infamous use of intracerebral Enterobacter. These early observations of tumor regression and concomitant infection piloted a burgeoning field focusing on the use of pathogens in molecular oncology.
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http://dx.doi.org/10.3171/2016.12.JNS162123DOI Listing
April 2018

Synopsis of Guidelines for the Clinical Management of Cerebral Cavernous Malformations: Consensus Recommendations Based on Systematic Literature Review by the Angioma Alliance Scientific Advisory Board Clinical Experts Panel.

Neurosurgery 2017 May;80(5):665-680

Department of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah.

Background: Despite many publications about cerebral cavernous malformations (CCMs), controversy remains regarding diagnostic and management strategies.

Objective: To develop guidelines for CCM management.

Methods: The Angioma Alliance ( www.angioma.org ), the patient support group in the United States advocating on behalf of patients and research in CCM, convened a multidisciplinary writing group comprising expert CCM clinicians to help summarize the existing literature related to the clinical care of CCM, focusing on 5 topics: (1) epidemiology and natural history, (2) genetic testing and counseling, (3) diagnostic criteria and radiology standards, (4) neurosurgical considerations, and (5) neurological considerations. The group reviewed literature, rated evidence, developed recommendations, and established consensus, controversies, and knowledge gaps according to a prespecified protocol.

Results: Of 1270 publications published between January 1, 1983 and September 31, 2014, we selected 98 based on methodological criteria, and identified 38 additional recent or relevant publications. Topic authors used these publications to summarize current knowledge and arrive at 23 consensus management recommendations, which we rated by class (size of effect) and level (estimate of certainty) according to the American Heart Association/American Stroke Association criteria. No recommendation was level A (because of the absence of randomized controlled trials), 11 (48%) were level B, and 12 (52%) were level C. Recommendations were class I in 8 (35%), class II in 10 (43%), and class III in 5 (22%).

Conclusion: Current evidence supports recommendations for the management of CCM, but their generally low levels and classes mandate further research to better inform clinical practice and update these recommendations. The complete recommendations document, including the criteria for selecting reference citations, a more detailed justification of the respective recommendations, and a summary of controversies and knowledge gaps, was similarly peer reviewed and is available on line www.angioma.org/CCMGuidelines .
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http://dx.doi.org/10.1093/neuros/nyx091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5808153PMC
May 2017

Ventriculoatrial versus ventriculoperitoneal shunt complications in idiopathic normal pressure hydrocephalus.

Clin Neurol Neurosurg 2017 Jun 18;157:1-6. Epub 2017 Mar 18.

Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Idiopathic normal pressure hydrocephalus (iNPH) is a devastating condition that affects the elderly population. Although ventriculoatrial (VA) shunts can be used to manage iNPH, concerns for associated cardiopulmonary and renal complications have decreased their use. However, the rate of these complications is not well understood within this population of patients.

Patients And Methods: A retrospective review of the electronic medical records of patients diagnosed with iNPH by the senior author between 1993 and 2015 was performed. Demographic information and baseline symptoms were assessed. Complications including infection, shunt obstruction, overdrainage, cardiopulmonary events, renal dysfunction, and shunt revision were recorded. Complication rates were compared between VA and VP shunted patients. Statistical analysis using Chi-square test, Fisher's exact test, logistic regression, Wald t-test, Poisson regression, ANOVA, and ANCOVA was performed.

Results: 496 Patients, including 150 receiving VA shunts and 346 receiving VP shunts, were included in the study. The median age was 74 and 73 for VA and VP shunted patients, respectively, with slight male predominance in both (58.0% and 58.4% for VA and VP groups, respectively). A total of 36.0% of VA shunted patients and 42.5% of VP shunted patients experienced at least one post-operative complication. Overdrainage was the most commonly experienced complication in both VA (27.4%) and VP patients (19.9%). Infection occurred in only 2.0% of patients, and renal complications occurred in 1.3%. No patients had cardiopulmonary complications. VA shunted patients were significantly less likely to experience shunt obstruction and require shunt revision compared to VP shunted patients (p=0.008 and <0.001, respectively). Only dizziness and gait disturbance at baseline were correlated with a shorter time to revision in VA shunted patients (p=0.002 for both).

Conclusion: Although cardiopulmonary and renal complications are serious concerns associated with VA shunt placement, they were uncommon in patients with iNPH. VA shunted patients were less likely to experience shunt obstruction and require shunt revision compared to VP shunted patients. Therefore, VA shunts should be considered as an alternative primary treatment option in the iNPH population.
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http://dx.doi.org/10.1016/j.clineuro.2017.03.014DOI Listing
June 2017

A Novel Experimental Animal Model of Adult Chronic Hydrocephalus.

Neurosurgery 2016 Nov;79(5):746-756

*Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland; ‡Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland; §F. M. Kirby Research Center for Functional Brain Imaging at the Kennedy Krieger Institute, School of Medicine, Johns Hopkins University, Baltimore, Maryland; ¶Department of Radiology and Radiological Science, School of Medicine, Johns Hopkins University, Baltimore, Maryland; ‖Department of Biomedical Engeniering, Johns Hopkins University, Baltimore, Maryland; #Department of Pathology, Division of Neurophatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland; **Department of Oncology, School of Medicine, Johns Hopkins University, Baltimore, Maryland; ‡‡Laboratory of Neuroscience, Facultad de Psicologia, University of Colima, Colima, Mexico; §§Department of Neurosurgery, School of Medicine in St. Louis, Washington University, St. Louis, Missouri; ¶¶Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland; ‖‖Department of Oncology, School of Medicine, Johns Hopkins University, Baltimore, Maryland.

Background: The pathogenesis of adult chronic hydrocephalus is not fully understood, and the temporal relationship between development of the radiological changes and neurological deterioration is unknown.

Objective: To clarify the progression of radiological-histological changes and subsequent clinical manifestations of adult chronic hydrocephalus.

Methods: Kaolin was injected bilaterally into the subarachnoid space overlying the cranial convexities in 20 adult rats. Magnetic resonance imaging (MRI) was obtained by using an 11.7 T scanner at 14, 60, 90, and 120 days after kaolin injection. Locomotor, gait, and cognitive evaluations were performed independently. Kaolin distribution and the associated inflammatory and fibrotic responses were histologically analyzed.

Results: Evans index of ventriculomegaly showed significant progressive growth in ventricular size over all time points examined. The greatest enlargement occurred within the first 2 months. Evans index also correlated with the extent of kaolin distribution by MRI and by pathological examination at all time points. First gait changes occurred at 69 days, anxiety at 80, cognitive impairment at 81, and locomotor difficulties after 120 days. Only locomotor deterioration was associated with Evans index or the radiological evaluation of kaolin extension. Inflammatory/fibrotic response was histologically confirmed over the cranial convexities in all rats, and its extension was associated with ventricular size and with the rate of ventricular enlargement.

Conclusion: Kaolin injected into the subarachnoid space over the cerebral hemispheres of adult rats produces an inflammatory/fibrotic response leading in a slow-onset communicating hydrocephalus that is initially asymptomatic. Increased ventricular size eventually leads to gait, memory, and locomotor impairment closely resembling the course of human adult chronic hydrocephalus.

Abbreviation: NPH, normal pressure hydrocephalus.
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http://dx.doi.org/10.1227/NEU.0000000000001405DOI Listing
November 2016

Choroid plexus hyperplasia: A possible cause of hydrocephalus in adults.

Neurology 2016 11 12;87(19):2058-2060. Epub 2016 Oct 12.

From the Departments of Neurosurgery (J.T.C., S.M.G., I.J.-T., B.D.E., C.R.G., M.R.H., D.R.) and Radiology and Radiological Science (A.M.B.), The Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1212/WNL.0000000000003303DOI Listing
November 2016

Early Detection of Lung Cancer Using DNA Promoter Hypermethylation in Plasma and Sputum.

Clin Cancer Res 2017 04 11;23(8):1998-2005. Epub 2016 Oct 11.

Sidney Kimmel Cancer Center, Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

CT screening can reduce death from lung cancer. We sought to improve the diagnostic accuracy of lung cancer screening using ultrasensitive methods and a lung cancer-specific gene panel to detect DNA methylation in sputum and plasma. This is a case-control study of subjects with suspicious nodules on CT imaging. Plasma and sputum were obtained preoperatively. Cases ( = 150) had pathologic confirmation of node-negative (stages I and IIA) non-small cell lung cancer. Controls ( = 60) had non-cancer diagnoses. We detected promoter methylation using quantitative methylation-specific real-time PCR and methylation-on-beads for cancer-specific genes (, and ). DNA methylation was detected in plasma and sputum more frequently in people with cancer compared with controls ( < 0.001) for five of six genes. The sensitivity and specificity for lung cancer diagnosis using the best individual genes was 63% to 86% and 75% to 92% in sputum, respectively, and 65% to 76% and 74% to 84% in plasma, respectively. A three-gene combination of the best individual genes has sensitivity and specificity of 98% and 71% using sputum and 93% and 62% using plasma. Area under the receiver operating curve for this panel was 0.89 [95% confidence interval (CI), 0.80-0.98] in sputum and 0.77 (95% CI, 0.68-0.86) in plasma. Independent blinded random forest prediction models combining gene methylation with clinical information correctly predicted lung cancer in 91% of subjects using sputum detection and 85% of subjects using plasma detection. High diagnostic accuracy for early-stage lung cancer can be obtained using methylated promoter detection in sputum or plasma. .
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http://dx.doi.org/10.1158/1078-0432.CCR-16-1371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366618PMC
April 2017

Predictors of admission and shunt revision during emergency department visits for shunt-treated adult patients with idiopathic intracranial hypertension.

J Neurosurg 2017 Aug 23;127(2):233-239. Epub 2016 Sep 23.

Department of Neurosurgery, Johns Hopkins University School of Medicine; and.

OBJECTIVE Factors associated with emergency department admission and/or shunt revision for idiopathic intracranial hypertension (IIH) are unclear. In this study, the associations of several factors with emergency department admission and shunt revision for IIH were explored. METHODS The authors performed a retrospective review of 31 patients (169 total emergency department visits) who presented to the emergency department for IIH-related symptoms between 2003 and 2015. Demographics, comorbidities, symptoms, IIH diagnosis and treatment history, ophthalmological examination, diagnostic lumbar puncture (LP), imaging findings, and data regarding admission and management decisions were collected. Multivariable general linear models regression analysis was performed to assess the predictive factors associated with admission and shunt revision. RESULTS Thirty-one adult patients with a history of shunt placement for IIH visited the emergency department a total of 169 times for IIH-related symptoms, with a median of 3 visits (interquartile range 2-7 visits) per patient. Five patients had more than 10 emergency department visits. Baseline factors associated with admission included male sex (OR 10.47, 95% CI 2.13-51.56; p = 0.004) and performance of an LP (OR 3.10, 95% CI 1.31-7.31; p = 0.01). Contrastingly, older age at presentation (OR 0.94, 95% CI 0.90-0.99; p = 0.01), and a greater number of prior emergency department visits (OR 0.94, 95% CI 0.89-0.99; p = 0.02) were slightly protective against admission. The presence of papilledema (OR 11.62, 95% CI 3.20-42.16; p < 0.001), Caucasian race (OR 40.53, 95% CI 2.49-660.09 p = 0.009), and systemic hypertension (OR 7.73, 95% CI 1.11-53.62; p = 0.03) were independent risk factors for shunt revision. In addition, a greater number of prior emergency department visits (OR 0.86, 95% CI 0.77-0.96; p = 0.009) and older age at presentation (OR 0.93, 95% CI 0.87-0.99; p = 0.02) were slightly protective against shunt revision, while there was suggestive evidence that presence of a programmable shunt (OR 0.23, 95% CI 0.05-1.14; p = 0.07) was a protective factor against shunt revision. Of note, location of the proximal catheter in the ventricle or lumbar subarachnoid space was not significantly associated with admission or shunt revision in the multivariable analyses. CONCLUSIONS The decision to admit a shunt-treated patient from the emergency department for symptoms related to IIH is challenging. Knowledge of factors associated with the need for admission and/or shunt revision is required. In this study, factors such as male sex, younger age at presentation, lower number of prior emergency department visits, and performance of a diagnostic LP were independent predictors of admission. In addition, papilledema was strongly predictive of the need for shunt revision, highlighting the importance of an ophthalmological examination for shunt-treated adults with IIH who present to the emergency department.
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http://dx.doi.org/10.3171/2016.5.JNS151303DOI Listing
August 2017

Timing of surgical treatment for idiopathic normal pressure hydrocephalus: association between treatment delay and reduced short-term benefit.

Neurosurg Focus 2016 Sep;41(3):E2

Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

OBJECTIVE A growing body of evidence suggests that longer durations of preoperative symptoms may correlate with worse postoperative outcomes following cerebrospinal fluid (CSF) diversion for treatment of idiopathic normal pressure hydrocephalus (iNPH). The aim of this study is to determine whether the duration of preoperative symptoms alters postoperative outcomes in patients treated for iNPH. METHODS The authors conducted a retrospective review of 393 cases of iNPH involving patients treated with ventriculoperitoneal (VP) shunting. The duration of symptoms prior to the operative intervention was recorded. The following outcome variables were assessed at baseline, 6 months postoperatively, and at last follow-up: gait performance, urinary continence, and cognition. RESULTS The patients' median age at shunt placement was 74 years. Increased symptom duration was significantly associated with worse gait outcomes (relative risk (RR) 1.055 per year of symptoms, p = 0.037), and an overall absence of improvement in any of the classic triad symptomology (RR 1.053 per year of symptoms, p = 0.033) at 6 months postoperatively. Additionally, there were trends toward significance for symptom duration increasing the risk of having no 6-month postoperative improvement in urinary incontinence (RR 1.049 per year of symptoms, p = 0.069) or cognitive symptoms (RR 1.051 per year of symptoms, p = 0.069). However, no statistically significant differences were noted in these outcomes at last follow-up (median 31 months). Age stratification by decade revealed that prolonging symptom duration was significantly associated with lower Mini-Mental Status Examination scores in patients aged 60-70 years, and lack of cognitive improvement in patients aged 70-80 years. CONCLUSIONS Patients with iNPH with longer duration of preoperative symptoms may not receive the same short-term benefits of surgical intervention as patients with shorter duration of preoperative symptoms. However, with longer follow-up, the patients generally reached the same end point. Therefore, when managing patients with iNPH, it may take longer to see the benefits of CSF shunting when patients present with a longer duration of preoperative symptoms.
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http://dx.doi.org/10.3171/2016.6.FOCUS16146DOI Listing
September 2016