Publications by authors named "Raj Shrivastava"

92 Publications

SWI/SNF chromatin remodeling complex alterations in meningioma.

J Cancer Res Clin Oncol 2021 Mar 14. Epub 2021 Mar 14.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA.

Purpose: While SWI/SNF chromatin remodeling complex alterations occur in approximately 20% of cancer, the frequency and potential impact on clinical outcomes in meningiomas remains to be comprehensively elucidated.

Methods: A large series of 255 meningiomas from a single institution that was enriched for high grade and recurrent lesions was identified. We performed next-generation targeted sequencing of known meningioma driver genes, including NF2, AKT1, PIK3CA, PIK3R1, and SMO and SWI/SNF chromatin remodeling complex genes, including ARID1A, SMARCA4, and SMARCB1 in all samples. Clinical correlates focused on clinical presentation and patient outcomes are presented.

Results: The series included 63 grade I meningiomas and 192 high-grade meningiomas, including 173 WHO grade II and 19 WHO grade III. Samples from recurrent surgeries comprised 37.3% of the series. A total of 41.6% meningiomas were from the skull base. NF2, AKT1, PIK3CA, PIK3R1, and SMO were mutated in 40.8, 7.1, 3.5, 3.9, and 2.4% of samples, respectively. ARID1A, SMARCA4, and SMARCB1 mutations were observed in 17.3, 3.5, and 5.1% of samples, respectively. A total of 68.2% of ARID1A-mutant meningiomas harbored a p.Gln1327del in-frame deletion. ARID1A mutations were seen in 19.1% of Grade I, 16.8% of Grade II, and 15.8% of Grade III meningiomas (P = 0.9, Fisher's exact). Median overall survival was 16.3 years (95% CI 10.9, 16.8). With multivariable analysis, the presence of an ARID1A mutation was significantly associated with a 7.421-fold increased hazard of death (P = 0.04).

Conclusion: ARID1A mutations occur with similar frequency between low and high-grade meningiomas, but ARID1A mutations are independently prognostic of worse prognosis beyond clinical and histopathologic features.
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http://dx.doi.org/10.1007/s00432-021-03586-7DOI Listing
March 2021

Tumor immune microenvironment in brain metastases from gynecologic malignancies.

Cancer Immunol Immunother 2021 Mar 13. Epub 2021 Mar 13.

Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.

Introduction: The density and distribution of the tumor immune microenvironment associated with brain metastases (BM) from gynecologic malignancies are unknown and have not been previously reported. We sought to describe the clinical features of a cohort of patients with BM from gynecologic malignancies and to characterize the tumor immune microenvironment from available archival surgical specimens.

Methods: We performed a retrospective review of electronic medical records from 2002 to 2018 for patients with BM from gynecologic malignancies. Data on patient characteristics, treatment regimens, and clinical outcomes were procured. CD4, CD8, CD45RO, CD68, CD163, and FOXP3 immunohistochemistry were evaluated from available archival surgical specimens from primary disease site and neurosurgical resection.

Results: A cohort of 44 patients with BM from gynecologic malignancies was identified, 21 (47.7%) endometrial primaries and 23 (52.3%) ovarian primaries. Tumor-infiltrating lymphocytes (TILs) and tumor-associated macrophages (TAMs) were evaluated in 13 primary cases and 15 BM cases. For the 13 primary cases, CD4 TILs were evident in 76.9% of cases, CD8 in 92.3%, CD45RO in 92.3%, and FOXP3 in 46.2%, as well as CD68 TAMs in 100% and CD163 in 100%. For the 15 BM cases, CD4 TILs were evident in 60.0% of cases, CD8 in 93.3%, CD45RO in 73.3%, and FOXP3 in 35.7%, as well as CD68 TAMs in 86.7% and CD163 in 100%.

Conclusion: An active tumor immune microenvironment is present with similar distribution in the primary disease site and BM from patients with gynecologic malignancies.
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http://dx.doi.org/10.1007/s00262-021-02909-4DOI Listing
March 2021

Spinal cord injury in the United States Army Special Forces.

J Neurosurg Spine 2020 Sep 25:1-7. Epub 2020 Sep 25.

3Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio.

Objective: Spinal cord injury (SCI) is an area of key interest in military medicine but has not been studied among the US Army Special Forces (SF), the most elite group of US soldiers. SF soldiers make up a disproportionate 60% of all Special Operations casualties. The objective of this study was to better understand SCI incidence in the SF, its mechanisms of acquisition, and potential areas for intervention by addressing key issues pertaining to protective equipment and body armor use.

Methods: An electronic survey questionnaire was formulated with the close collaboration of US board-certified neurosurgeons from the Mount Sinai Hospital and Cleveland Clinic Departments of Neurosurgery, retired military personnel of the SF, and operational staff of the Green Beret Foundation. The survey was sent to approximately 6000 SF soldiers to understand SCI diagnosis and its associations with various health and military variables.

Results: The response rate was 8.2%. Among the 492 respondents, 94 (19.1%) self-reported an SCI diagnosis. An airborne operation was the most commonly attributed cause (54.8%). Moreover, 87.1% of SF soldiers reported wearing headgear at the time of injury, but only 36.6% reported wearing body armor, even though body armor use has significantly increased in post-9/11 SF soldiers compared with that in their pre-9/11 counterparts. SCI was significantly associated with traumatic brain injury, arthritis, low sperm count, low testosterone, erectile dysfunction, tinnitus, hyperacusis, sleep apnea, posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder. Only 16.5% of SF soldiers diagnosed with SCI had been rescued via medical evacuation (medevac) for treatment.

Conclusions: A high number of SF soldiers self-reported an SCI diagnosis. Airborne operations landings were the leading cause of SCI, which coincided with warfare tactics employed during the Persian Gulf War, Operation Iraqi Freedom, and other conflicts. A majority of SCIs occurred while wearing headgear and no body armor, suggesting the need for improvements in protective equipment use and design. The low rate of medevac rescue for these injuries may suggest that medical rescue was not attainable at the time or that certain SCIs were deemed minor at the time of injury.
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http://dx.doi.org/10.3171/2020.7.SPINE20804DOI Listing
September 2020

Peritumoral edema correlates with mutational burden in meningiomas.

Neuroradiology 2021 Jan 12;63(1):73-80. Epub 2020 Aug 12.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA.

Purpose: Meningiomas are the most common primary central nervous system tumor. Emerging data supports that higher mutational burden portends worse clinical outcomes in meningiomas. However, there is a lack of imaging biomarkers that are associated with tumor genomics in meningiomas.

Methods: We performed next-generation targeted sequencing in a cohort of 75 primary meningiomas and assessed preoperative imaging for tumor volume and peritumoral brain edema (PTBE). An Edema Index was calculated.

Results: Meningiomas that were high grade (WHO grade II or grade III) had significantly larger tumor volume and were more likely to present with PTBE. Moreover, PTBE was associated with brain invasion on histopathology and reduced overall survival. There was a direct association between Edema Index and mutational burden. For every one increase in Edema Index, the number of single nucleotide variants increased by 1.09-fold (95% CI: 1.02, 1.2) (P = 0.01).

Conclusion: These data support that Edema Index may serve as a novel imaging biomarker that can inform underlying mutational burden in patients with meningiomas.
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http://dx.doi.org/10.1007/s00234-020-02515-8DOI Listing
January 2021

Endoscopic Muscle Repair of Right Internal Carotid Artery Rupture Following Endovascular Procedure.

Laryngoscope 2021 03 3;131(3):E764-E766. Epub 2020 Aug 3.

Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, U.S.A.

Carotid artery blowout syndrome (CBS) is a deadly complication usually linked to head and neck cancer therapy. We present a different etiology of endoscopic CBS, a complication of endovascular coiling of an intracranial aneurysm, treated with sternocleidomastoid (SCM) muscle graft packing. Case Presentation: An otherwise healthy 55-year-old female presented to the emergency room with right-sided painless vision loss of 23 days. Computed tomography angiography demonstrated a right ophthalmic ICA aneurysm eroding into the right sphenoid sinus with optic nerve compression. Attempted endovascular repair of the aneurysm was complicated by ICA rupture into the sphenoid. An endovascular balloon was inflated proximal to the aneurysm to reduce hemorrhage as ENT performed an endoscopic sphenoidotomy. A hematoma was seen overlying the aneurysm in the superior lateral sphenoid sinus. Layers of SCM muscle were morselized and packed serially. Post-repair angiography showed no further extravasation. Aggressive antiplatelet therapy was initiated. Packing was removed after 14 days. Twenty days postoperatively, the patient had profuse left-sided epistaxis requiring a left sphenopalatine artery ligation. The patient's vision recovered. Discussion: Whereas CBS is often managed by endovascular coil embolism, in our case CBS was caused by this very treatment itself. This case shows the use of SCM muscle graft as an effective repair modality of ICA rupture due to endovascular coiling. Laryngoscope, 131:E764-E766, 2021.
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http://dx.doi.org/10.1002/lary.28945DOI Listing
March 2021

NF2 mutation status and tumor mutational burden correlate with immune cell infiltration in meningiomas.

Cancer Immunol Immunother 2021 Jan 13;70(1):169-176. Epub 2020 Jul 13.

Department of Pathology, Icahn School of Medicine At Mount Sinai, New York, NY, USA.

Background: The tumor microenvironment is an emerging biomarker of underlying genomic heterogeneity and response to immunotherapy-based treatment regimens in solid malignancies. How tumor mutational burden influences the density, distribution, and presence of a localized immune response in meningiomas is unknown.

Methods: Representative hematoxylin and eosin slides were reviewed at 40X to assess for the density of inflammatory cells. Lymphocytes and macrophages were quantified in the following ordinal manner: 0 = not present, 1 = 1-25 cells present, and 2 = greater than 26 cells present. Immune cell infiltrate grade was scored for both scattered and aggregated distributions. Next generation targeted sequencing was performed on all meningiomas included in this study.

Results: One hundred and forty-five meningiomas were evaluated in this study. Lymphocytes were observed in both scattered (95.9%) and aggregated (21.4%) distributions. A total of 115 (79.3%) meningiomas had 1-25 scattered lymphocytes, and 24 (16.6%) had > 25 scattered lymphocytes, and 6 (4.1%) had no scattered lymphocytes. Twenty (13.8%) meningiomas had 1-25 aggregated lymphocytes. Eleven (7.6%) had > 25 aggregated lymphocytes and 114 (78.6%) had no aggregated lymphocytes. Six (4.1%) meningiomas had 1-25 aggregated macrophages, 5 (3.4%) had > 25 aggregated macrophages, and 134 (92.4%) had no aggregated macrophages. Density of aggregated lymphocytes and aggregated macrophages were associated with higher tumor grade, P = 0.0071 and P = 0.0068, respectively. Scattered lymphocyte density was not associated with meningioma grade. The presence of scattered lymphocytes was associated with increased tumor mutational burden. Meningiomas that did not have scattered lymphocytes had a mean number of single mutations of 2.3 ± 2.9, compared with meningiomas that had scattered lymphocytes, 6.9 ± 20.3, P = 0.03. NF2 mutations were identified in 59 (40.7%) meningiomas and were associated with increased density of scattered lymphocytes. NF2 mutations were seen in 0 (0%) meningiomas that did not have scattered lymphocytes, 46 (40.0%) meningiomas that had 1-25 scattered lymphocytes, and 13 (54.2%) meningiomas that had > 25 scattered lymphocytes, P = 0.046.

Conclusions: Our findings suggest that distribution of immune cell infiltration in meningiomas is associated with tumor mutational burden. NF2 mutational status was associated with an increasing density of scattered lymphocytes. As the role of immunotherapy in meningiomas continues to be elucidated with clinical trials that are currently underway, these results may serve as a novel biomarker of tumor mutational burden in meningiomas.
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http://dx.doi.org/10.1007/s00262-020-02671-zDOI Listing
January 2021

Surgical outcomes in patients with endoscopic versus transcranial approach for skull base malignancies: a 10-year institutional experience.

Br J Neurosurg 2020 Jun 15:1-7. Epub 2020 Jun 15.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

The authors performed an extensive comparison between patients treated with open versus an endoscopic approach for skull base malignancy with emphasis on surgical outcomes. A single-institution retrospective review of 60 patients who underwent surgery for skull base malignancy between 2009 and 2018 was performed. Disease features, surgical resection, post-operative morbidities, adjuvant treatment, recurrence, and survival rates were compared between 30 patients who received purely open surgery and 30 patients who underwent purely endoscopic resection for a skull base malignancy. Of the 60 patients with skull base malignancy, 30 underwent open resection and 30 underwent endoscopic resection. The most common hisotype for endoscopic resection was squamous cell carcinoma (26.7%), olfactory neuroblastoma (16.7%), and sarcoma (10.0%), and 43.3%, 13.3%, and 10.0% for the open resection cohort, respectively. There were no statistical differences in gross total resection, surgical-associated cranial neuropathy, or ability to achieve negative margins between the groups ( > 0.1, all comparisons). Patients who underwent endoscopic resection had shorter surgeries (320.3 ± 158.5 minutes vs. 495.3 ± 187.6 minutes ( = 0.0003), less intraoperative blood loss (282.2 ± 333.6 ml vs. 696.7 ± 500.2 ml ( < 0.0001), and shorter length of stay (3.5 ± 3.7 days vs. 8.8 ± 6.0 days ( < 0.0001). Additionally, patients treated endoscopically initiated adjuvant radiation treatment more quickly (48.0 ± 20.3 days vs. 72.0 ± 20.5 days ( = 0.01). An endoscopic endonasal approach facilitates a clinically meaningful improvement in surgical outcomes for skull base malignancies.
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http://dx.doi.org/10.1080/02688697.2020.1779659DOI Listing
June 2020

Endoscopic Skull Base Surgery Protocol From the Frontlines: Transnasal Surgery During the COVID-19 Pandemic.

Otolaryngol Head Neck Surg 2020 09 26;163(3):482-490. Epub 2020 May 26.

Department of Neurosurgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objective: The coronavirus disease 2019 (COVID-19) pandemic disrupted the standard management paradigms for care of patients with sinus and skull base presentations due to concern for patient and health care provider safety, given the high aerosol-generating potential of endonasal procedures.

Data Sources: We reviewed the relevant literature complied from available sources, including PubMed, Google Scholar, and otolaryngology journals providing electronic manuscripts ahead of indexing or publication.

Review Methods: Incorporating available evidence and the projected infection control and resource limitations at our institution, we collectively authored a dynamic set of protocols guiding (1) case stratification, (2) preoperative assessment, (3) operative setup, and (4) postoperative care of patients with sinus or skull base presentations. Due to the rapidly evolving nature of COVID-19 publications, lack of rigorous data, and urgent necessity of standardized protocols, strict inclusion and exclusion criteria were not employed.

Conclusions: As scarce hospital resources are diverted to COVID-19 care and staff are redeployed to forward-facing roles, endonasal procedures have largely ceased, leaving patients with ongoing sinonasal and skull base complaints untreated. Skull base teams now weigh the urgency of surgery in this population with the regional availability of resources.

Implications For Practice: The COVID-19 pandemic will have an enduring and unpredictable impact on hospital operations and surgical skull base practices and will require a dynamic set of management protocols responsive to new evidence and changing resources. In the current resource-limited environment, clinicians may utilize these protocols to assist with stratifying patients by acuity, performing preoperative assessment, and guiding peri- and postoperative care.
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http://dx.doi.org/10.1177/0194599820931836DOI Listing
September 2020

Letter to the Editor: Changes in Neurosurgery Resident Education During the COVID-19 Pandemic: An Institutional Experience from a Global Epicenter.

World Neurosurg 2020 08 8;140:439-440. Epub 2020 May 8.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2020.04.244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207143PMC
August 2020

Cerebral Fungal Abscess in an Immunocompetent Patient.

Neurohospitalist 2020 Apr 26;10(2):145-147. Epub 2019 Aug 26.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

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http://dx.doi.org/10.1177/1941874419870985DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191670PMC
April 2020

Neurosurgical management of brain and spine tumors in the COVID-19 era: an institutional experience from the epicenter of the pandemic.

J Neurooncol 2020 Jun 5;148(2):211-219. Epub 2020 May 5.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, 1468 Madison Ave., New York, NY, USA.

The challenges of neurosurgical patient management and surgical decision-making during the 2019-2020 COVID-19 worldwide pandemic are immense and never-before-seen in our generation of neurosurgeons. In this case-based formatted report, we present the Mount Sinai Hospital (New York, NY) Department of Neurosurgery institutional experience in the epicenter of the pandemic and the guiding principles for our current management of intracranial, skull base, and spine tumors. The detailed explanations of our surgical reasoning for each tumor case is tailored to assist neurosurgeons across the United States as they face these complex operative decisions put forth by the realities of the pandemic.
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http://dx.doi.org/10.1007/s11060-020-03523-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7200051PMC
June 2020

STK11 mutation status is associated with decreased survival in meningiomas.

Neurol Sci 2020 Sep 7;41(9):2585-2589. Epub 2020 Apr 7.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA.

Background: Emerging evidence suggests that STK11 mutations may influence clinical outcome and response to immunotherapy in cancer.

Materials And Methods: Next-generation targeted sequencing of STK11 mutation status in a large cohort of 188 meningiomas.

Results: STK11 loss-of-function mutations were identified in 3.7% of meningiomas. STK11 mutations were found in both low- and high-grade lesions and samples from primary and recurrent disease. There was a 2.8-fold increased risk of death for patients whose meningioma harbored an STK11 mutation, after controlling for lesion grade and occurrence status. The median overall survival for patients with STK11-mutated meningiomas was 4.4 years compared with 16.8 years.

Conclusion: These data identify recurrent STK11 mutations in a subset of meningiomas. Genotyping of STK11 is encouraged for meningioma patients undergoing immunotherapy-based therapy.
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http://dx.doi.org/10.1007/s10072-020-04372-yDOI Listing
September 2020

Pituitary adenoma consistency: Direct correlation of ultrahigh field 7T MRI with histopathological analysis.

Eur J Radiol 2020 May 3;126:108931. Epub 2020 Mar 3.

Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.

Purpose: Tumor consistency is a critical factor in surgical planning that influences ease of resection and risk of operative morbidity. The ability of MRI to predict tumor consistency tumor consistency has been shown to increase with higher field strength. The present study examined the utility of 7 T (7 T) MRI in predicting the tumor consistency of pituitary adenomas.

Method: Fifteen patients with pituitary adenomas were preoperatively scanned at 7 T MRI. Regions of interest were drawn around lesions for voxel-based signal intensity (SI) analysis. The percentage of tumor voxels with intensity higher than local gray matter was calculated on T2-weighted imaging. A single neurosurgeon rated tumor firmness for all patients. Histopathological analysis was performed. Radiological tumor features were correlated with intraoperative tumor consistency measurements and histopathology.

Results: Tumors rated as 'soft' intraoperatively were hyperintense to local gray matter on T2-weighted imaging. 'Firm' tumors were hypointense to local gray matter. There was no significant difference in SI ratio between soft and firm tumors (p = 0.098). Soft tumors had a significantly higher percentage of tumor voxels greater than local gray matter compared to firm tumors (p = 0.035, Cohen's D-effect size = 1.208). Soft tumors had higher vascularity than firm tumors, p = 0.015.

Conclusions: The signal and contrast advantage conferred by 7 T MRI may provide valuable preoperative information regarding pituitary tumor consistency and physiology. The use of granular, voxel-based analysis maximizes the potential afforded by the high resolution of 7 T imaging, and may be a valuable method of predicting consistency of pituitary adenoma.
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http://dx.doi.org/10.1016/j.ejrad.2020.108931DOI Listing
May 2020

Analysis of 7-tesla diffusion-weighted imaging in the prediction of pituitary macroadenoma consistency.

J Neurosurg 2020 Feb 28:1-9. Epub 2020 Feb 28.

1Translational and Molecular Imaging Institute; and.

Objective: Endoscopic surgery is an effective treatment strategy for pituitary adenomas; however, intrinsic tumor properties such as tumor consistency can challenge or preclude gross-total resection. Preoperative characterization of tumor consistency may help to guide the surgical approach and to predict the extent of resection that is possible. Advanced radiological modalities such as 7T diffusion-weighted imaging (DWI) may be useful in probing biological tissue properties of pituitary adenomas. The objective of the present study was to examine 7T DWI as a novel method of measuring the consistency of pituitary adenomas.

Methods: Thirteen patients with pituitary macroadenomas underwent 7T MRI, including a DWI image acquisition. Tumor apparent diffusion coefficient (ADC) was normalized to the adjacent temporal gray matter ADC. All patients underwent resection, and a single neurosurgeon blinded to ADC values rated tumor firmness from 1 (least firm) to 5 (most firm) using objective criteria. The tumor specimens were evaluated histopathologically for cellularity, collagen content, and vascularity by a neuropathologist who was also blinded to ADC values. The tumor ADC was correlated with intraoperative consistency rating, histopathology, and extent of resection. Receiver operating characteristic (ROC) curve analyses were performed to identify thresholds to predict tumor consistency.

Results: Corrected ADC values were significantly correlated with both tumor firmness (r = -0.60, p = 0.029) and the extent of trichrome staining (r = -0.72, p = 0.009) such that greater ADC values were associated with both decreased tumor firmness and decreased collagen staining. Correlations between ADC values and tumor vascularity were not significant (r = -0.09, p = 0.78). Corrected ADC values in totally resected tumors (1.54) were greater than those in subtotally resected tumors (0.85) (p = 0.02), and ADC values were greater with moderate tumor cellularity (1.51) than with high tumor cellularity (0.8) (p = 0.035). There was a trend-level association for partial resections to exhibit greater tumor firmness rating (3 vs 1.7; p = 0.051). Finally, the degree of trichrome staining positively correlated with tumor firmness (r = 0.60, p = 0.04). The optimal threshold for predicting intraoperative consistency rating was an ADC ratio of 0.87 (sensitivity 80%, specificity 100%, area under the curve [AUC] 0.90; p = 0.043). The optimal cutoff for distinguishing the extent of resection was 1.19 (sensitivity 85.7%, specificity 83.3% AUC 0.833; p = 0.046).

Conclusions: The authors' results suggest that a high-resolution ADC of pituitary adenomas is a sensitive measure of tumor consistency. 7T DWI may hold clinical value in the preoperative workup and surgical management of patients with pituitary macroadenomas.
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http://dx.doi.org/10.3171/2019.12.JNS192940DOI Listing
February 2020

In Reply: Emerging Therapeutic Targets in Chordomas: A Review of the Literature in the Genomic Era.

Neurosurgery 2020 05;86(5):E483

Department of Neurosurgery Icahn School of Medicine Mount Sinai Medical Center New York, New York.

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http://dx.doi.org/10.1093/neuros/nyaa008DOI Listing
May 2020

Tumor T2 signal intensity and stalk angulation correlates with endocrine status in pituitary adenoma patients: a quantitative 7 tesla MRI study.

Neuroradiology 2020 Apr 10;62(4):473-482. Epub 2020 Jan 10.

Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Purpose: Pituitary adenomas are common CNS tumors that can cause endocrine dysfunction due to hormone oversecretion and by mass effect on the normal gland. The study of pituitary adenomas and adjacent sellar anatomy with high-resolution 7 T MRI may further characterize endocrine dysfunction. The purpose of this study was to determine the efficacy of 7 T MRI in identifying radiological markers for endocrine function.

Methods: MR images obtained in 23 patients with pituitary adenomas were reviewed by consensus between three neuroradiologists. Landmarks and criteria were devised to measure radiological features of stalk, tumor, and normal gland. Fischer's exact tests and nominal logistic regression were performed.

Results: Mean cross-sectional area of the stalk just below the infundibular recess was 6.3 ± 3.7 mm. Mean curvature and deviation angles were 34.2° ± 23.2° and 29.7° ± 17.3°, respectively. Knosp scores obtained differed between 7 T and lower field strength scans (P < 0.0001 [right] and P = 0.0006 [left]). Ability to characterize tumor was rated higher at 7 T compared with lower field MRI, P = 0.05. Confidence in visualizing normal gland was also higher using 7 T MRI, P = 0.036. The six hormone-secreting tumors had higher corrected T2 mean SI than non-secreting tumors (2.54 vs. - 0.38, P = 0.0196). Seven patients had preoperative hypopituitarism and had significantly greater stalk curvature angles than patients without hypopituitarism (71.7° vs. 36.55°, P = 0.027).

Conclusion: Radiological characterization of pituitary adenomas and adjacent native pituitary tissue may benefit with the use of 7 T MRI. Corrected T2 SI of tumor may be a sensitive predictor of hormonal secretion and may be useful in the diagnostic work-up for pituitary adenoma. 7 T MRI may be valuable in identifying markers of endocrine function in patients with pituitary adenomas. Our results indicate that hormone-secreting tumors have higher T2-weighted SI and tumors associated with preoperative hypopituitarism have greater stalk curvature angles.
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http://dx.doi.org/10.1007/s00234-019-02352-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205143PMC
April 2020

Correlation of spontaneous and traumatic anterior skull base CSF leak flow rates with fluid pattern on early, delayed, and subtraction volumetric extended echo train T2-weighted MRI.

J Neurosurg 2019 Dec 27:1-9. Epub 2019 Dec 27.

3Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York.

Objective: CSF leakage is a potentially fatal condition that may result when a skull base dural defect permits CSF communication between the cranial vault and sinonasal cavities. Flow rate is an important property of CSF leaks that can contribute to surgical decision-making and predispose patients to complications and inferior outcomes. Noninvasive preoperative prediction of the leak rate is challenging with traditional diagnostic tools. The present study compares fluid configurations on early and late volumetric extended echo train T2-weighted MRI by using image tracings and sequence subtraction as a novel method of quantifying CSF flow rate, and it correlates radiological results with intraoperative findings and clinical outcomes.

Methods: A total of 45 patients met inclusion criteria for this study and underwent 3-T MRI. Imaging sequences included two identical CUBE T2 (vendor trade name for volumetric extended echo train T2) acquisitions at the beginning and end of the scanning session, approximately 45 minutes apart. Twenty-five patients were confirmed to have definitive spontaneous or traumatic anterior skull base CSF leaks. Semiautomated volumetric segmentation of CSF intensity was performed on both CUBE data sets by using 3D-Slicer software, and volumes were subtracted to obtain accumulated CSF volume. These imaging-derived fluid accumulations were correlated with high- or low-flow states, as well as ultimate treatment outcomes including recurrences.

Results: Of the 45 patients, 25 (55.6%) had definitive evidence of CSF leakage, and 22 (88%) of these underwent surgical repair. Patients with high-flow CSF leaks had higher early (4.058 cm3 vs 0.982 cm3, p = 0.04), late (4.58 cm3 vs 1.096 cm3, p = 0.04), and accumulated (0.53 cm3 vs 0.11 cm3, p = 0.01) fluid volume measurements than patients with low-flow leaks. The 5 (22.7%) patients who exhibited postoperative CSF leak recurrence had significantly greater early (6.30 cm3 vs 1.23 cm3, p = 0.008) and late (6.87 cm3 vs 1.45 cm3, p = 0.008) volumes. Accumulated volume was not significantly greater in patients with leak recurrence (0.58 cm3 vs 0.22 cm3, p = 0.07). Early, late, and accumulated volumes were significantly correlated with postoperative hospital stay as well as duration of postoperative lumbar drain placement (p < 0.05 for all measures).

Conclusions: High-resolution CUBE T2 MRI, coupled with precise volumetric segmentation and subtraction of sinonasal hyperintensity, not only demonstrated predictive value in differentiating low- and high-flow CSF leaks, but also correlated with postoperative complications such as leak recurrence. These findings may be useful in the clinical workup and neurosurgical management of patients with skull base CSF leaks.
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http://dx.doi.org/10.3171/2019.10.JNS192500DOI Listing
December 2019

Use of Mixed Reality Visualization in Endoscopic Endonasal Skull Base Surgery.

Oper Neurosurg (Hagerstown) 2020 07;19(1):43-52

Icahn School of Medicine at Mount Sinai, New York, New York.

Background: Neuronavigation systems assist with spatial orientation during endoscopic transnasal skull base surgery, but they require a correlation of 3-dimensional (3D) views with 2-dimensional (2D) radiology studies.

Objective: To outline an initial experience with a novel technology platform that provides intraoperative navigation using 3D reconstructions of patient anatomy for endoscopic surgery.

Methods: A retrospective study of endoscopic anterior skull base and complex paranasal procedures was performed. Data from preoperative computed tomography and magnetic resonance imaging scans were fused to create 3D digital models of patient anatomy. Using the technology developed by Surgical Theater (Mayfield Village, Ohio), these reconstructions were designed to highlight particular anatomic regions of interest. The models were studied to guide the surgical approach and anticipate critical structures.The reconstructions were linked with the navigational technology created by Brainlab (Munich, Germany) during endoscopic surgery. A dynamic image of the reconstruction was displayed alongside a matching endoscopic camera view. These 2 views could be overlaid to provide an immersive, mixed reality image of the patient's anatomy.

Results: A total of 134 cases were performed. The pathologies included tumors of the anterior skull base or sinonasal cavity, inflammatory sinus disease, and cerebrospinal fluid leaks. Specific anatomic structures, such as the internal carotid arteries and optic nerves, were chosen for enhancement. Surgeons felt that the technology helped to guide the extent of bony dissection and to identify critical structures.

Conclusion: We describe the first clinical series of complex skull base pathologies treated using a novel mixed reality platform.
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http://dx.doi.org/10.1093/ons/opz355DOI Listing
July 2020

Neuroanatomical Determinants of Secondary Trigeminal Neuralgia: Application of 7T Ultra-High-Field Multimodal Magnetic Resonance Imaging.

World Neurosurg 2020 05 29;137:e34-e42. Epub 2019 Nov 29.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Seven-Tesla (7T) magnetic resonance imaging (MRI) has demonstrated value for evaluating a variety of intracranial diseases. However, its utility in trigeminal neuralgia has received limited attention. The authors of the present study applied ultra-high field multimodal MRI to two representative patients with secondary trigeminal neuralgia due to epidermoid tumors to illustrate the possible clinical and surgical advantages of 7T compared with standard clinical strength imaging. Techniques included co-registration of multiple 7T sequences to optimize the detection of potential concurrent neurovascular and neoplasm-derived compression.

Methods: 7T MRI studies were performed using a whole body scanner. Two- and three-dimensional renderings of potential neurovascular conflict were created by co-registering time-of-flight angiography and T2-weighted turbo spin echo images in MATLAB and GE software. Detailed comparisons of the various field strength images were provided by a collaborating neuroradiologist (B.D.).

Results: 7T MRI clearly illustrated minute tumor-adjacent vasculature. In contrast, conventional, low-field imaging did not consistently provide adequate details to distinguish cerebrospinal fluid pulsatility from vessels. The tumor margins, although distinct from the trigeminal nerve fibers at 7T, blended with those of the surrounding structures at 3T. Two- and three-dimensional co-registration of time-of-flight angiography with T2-weighted MRI suggested that delicate, intervening vasculature may have contributed to these illustrative patients' symptomatology.

Conclusions: 7T provided superior visualization of vital landmarks and subtle nerve and vessel features. Co-registration of various advanced 7T modalities may help to resolve complex disease etiologies. Future studies should explore the extent to which this dual etiology might persist across tumor types and utilize diffusion-based techniques to quantify what microstructural differences might exist between patients with trigeminal neuralgia from varying etiologies.
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http://dx.doi.org/10.1016/j.wneu.2019.11.130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202996PMC
May 2020

Hospital Charge Variability across New York State: Sociodemographic Factors in Pituitary Surgery.

J Neurol Surg B Skull Base 2019 Dec 4;80(6):612-619. Epub 2019 Jan 4.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States.

 Significant charge disparities exist across New York State (NYS). Race and income are associated with increased charges. To determine risk factor, we correlate hospital charges for pituitary surgery with socioeconomic factors. Additionally, we identify patients at risk for increased hospital charges and provide insight into cost-effective practices.  Retrospective cohort study of the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health was conducted. The SPARCS database was reviewed. Patients who underwent transsphenoidal pituitary surgery from 1995 to 2015 were identified. Income and urban status were referenced from U.S. census data. Linear regression was performed to analyze the effect of sociodemographic factors, comorbidities, and complications on hospital charges while controlling for length of stay.  A total of 9,373 patients were identified. Black (10.8%,  < 0.001) and Asian (14.5%,  < 0.001) had higher hospital charges. Patients from nonurban cities (13.4%,  < 0.001), Medicaid (13.8%,  < 0.001), and those from the 0 to 25th (9.1%,  < 0.001) and 25 to 50th (11.7%,  < 0.001) income quartile had lower hospital charges. Patients with postoperative cerebrospinal fluid leak (24.0%,  < 0.001), diabetes insipidus (22.1%,  < 0.001), smoking history (11.8%,  < 0.001), hypertension (7.4%,  < 0.001), and hypothyroidism (6.9%,  < 0.001) had higher hospital charges.  Patients incurring higher chargers were more likely to have a smoking history, hypertension, hypothyroidism, and comorbidities. The determinants of this analysis may provide insight into barriers to patient access and cost improvement strategies. In addition, this emphasizes the need for future studies to create a risk stratification model, similar to those in other fields.
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http://dx.doi.org/10.1055/s-0038-1676839DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6864428PMC
December 2019

Brain Metastases from Biliary Tract Cancers: A Case Series and Review of the Literature in the Genomic Era.

Oncologist 2020 05 6;25(5):447-453. Epub 2019 Nov 6.

Department of Neurosurgery, Mount Sinai Medical Center, New York, New York, USA.

Background: Biliary tract cancers (BTCs) are highly fatal malignancies that make up less than 1% of all cancers. BTC is often diagnosed at an unresectable stage; surgical resection remains the only definitive treatment. Brain metastases (BMs) from BTC are extremely rare, and few studies on patients with BMs from BTC exist. The aim of this study was to identify clinical characteristics associated with poor prognosis for patients with BMs from BTC.

Materials And Methods: We performed a retrospective review of electronic medical records for patients with BMs from BTC managed at Mount Sinai Hospital from 2000 to 2017. Data on patient characteristics, magnetic resonance imaging findings, treatment regimens, and clinical outcomes were analyzed.

Results: We identified 1,910 patients with BTC. Nine patients developed BMs, with an incidence of 0.47%. Of these nine patients, six had intrahepatic cholangiocarcinoma, two had extrahepatic cholangiocarcinoma, and one had gallbladder cancer. Six (66.7%) patients had one BM, one (11.1%) patient had two BMs, and two (22.2%) patients had three or more BMs. Four (44.4%) patients underwent BM resection, and seven (77.8%) received BM radiation. Median overall survival from time of BM diagnosis was 3.8 months (95% confidence interval 0.1-16.9).

Conclusion: Development of BMs from BTC is rare; however, prognosis is less than 4 months. BM diagnosis can occur within 2 years of primary diagnosis. As targeted therapeutics emerge, future studies ought to focus on identifying genomic BM markers associated with BTC subtypes.

Implications For Practice: In the largest retrospective study of biliary tract cancer brain metastases, the clinical presentation and outcomes are reported of nine patients with an extremely rare clinical entity. The genomic literature and potential therapeutic targets for these patients with limited treatment options is comprehensively and exhaustively discussed.
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http://dx.doi.org/10.1634/theoncologist.2019-0306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216433PMC
May 2020

Reappraising the Tolosa-Hunt Syndrome Diagnostic Criteria: A Case Series.

Headache 2020 01 4;60(1):259-264. Epub 2019 Nov 4.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Introduction: Tolosa-Hunt syndrome (THS), a condition characterized by painful ophthalmoplegia and accompanied by cranial nerve palsies, remains as a diagnosis of exclusion. Nevertheless, the 3rd Edition of the International Classification of Headache Disorders (ICHD) has refined its diagnostic criteria to require the demonstration of granulomatous inflammation on magnetic resonance imaging or biopsy. We sought to assess the effectiveness of the new criteria in arriving at accurate diagnoses.

Methods: We extracted all patient charts from our institution's electronic medical record associated with ICD-9 code 378.55 (external ophthalmoplegia). We then completed the retrospective diagnostic workups to determine if subjects met ICHD-3 criteria for THS and compared our findings with their final diagnoses.

Results: Of 62 patients associated with ICD-9 code 378.55, 10 (16%) was identified to have presenting symptoms concerning THS. The average age at the first onset of THS-like symptoms was 58 years. Five of the 10 (50%) met ICHD-3 criteria for THS. Two of the 5 (40%) meeting ICHD-3 criteria for THS were discovered to have other diagnoses. Two of the 5 (40%) patients not meeting ICHD-3 criteria for THS nevertheless received a final diagnosis of THS.

Discussion: Our false-negative rate of 40% is consistent with previous case series found in the literature. Our false-positive rate of 40% is, to our knowledge, a new contribution to the literature as no other case series includes more than a single false-positive. The false-positive rate is most concerning, as a preliminary misdiagnosis of THS can delay treatment tailored to the true etiology. Furthermore, infectious etiologies can be exacerbated with steroid treatment.

Conclusion: Our case series suggests that ICHD-3 criteria are suboptimal for the accurate diagnosis of THS. We recommend a close follow-up for all patients with symptoms concerning THS until a definitive responsible etiology is discovered and we encourage further studies assessing ICHD-3 guidelines to optimize their sensitivity and specificity in the diagnosis of THS.
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http://dx.doi.org/10.1111/head.13692DOI Listing
January 2020

Clinical impact of intraoperative hyperlactatemia during craniotomy.

PLoS One 2019 24;14(10):e0224016. Epub 2019 Oct 24.

Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America.

Object: Patients often develop markedly elevated serum lactate levels during craniotomy although the reason for this is not entirely understood. Elevated lactate levels have been associated with poor outcomes in critically ill septic shock patients, as well as patients undergoing abdominal and cardiac surgeries. We investigated whether elevated lactate in craniotomy patients is associated with neurologic complications (new neurological deficits) as well as systemic complications.

Methods: We performed a cohort study of elective craniotomy patients. Demographic and intraoperative data were collected, as well as three timed intraoperative arterial lactate values. Additional lactate, creatinine and troponin values were collected immediately postoperatively as well as 12 and 24 hours postoperatively. Assessment for neurologic deficit was performed at 6 hours and 2 weeks postoperatively. Hospital length-of-stay and 30-day mortality were collected.

Results: Interim analysis of 81 patients showed that no patient had postoperative myocardial infarction, renal failure, or mortality within 30 days of surgery. There was no difference in the incidence of new neurologic deficit in patients with or without elevated lactate (10/26, 38.5% vs. 15/55 27.3%, p = 0.31). Median length of stay was significantly longer in patients with elevated lactate (6.5 vs. 3 days, p = 0.003). Study enrollment was terminated early due to futility (futility index 0.16).

Conclusion: Elevated intraoperative serum lactate was not associated with new postoperative neurologic deficits, other end organ events, or 30 day mortality. Serum lactate was related to longer hospital stay.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0224016PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812741PMC
March 2020

Primary visual cortical thickness in correlation with visual field defects in patients with pituitary macroadenomas: a structural 7-Tesla retinotopic analysis.

J Neurosurg 2019 Oct 18:1-11. Epub 2019 Oct 18.

1Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai.

Objective: Vision loss remains a debilitating complication of pituitary adenomas, although there is considerable variability in visual impairment before and after decompression surgery. Growing evidence suggests secondary damage to remote visual structures may contribute to vision loss in patients with chiasmatic compression. The present study leverages ultrahigh field 7-T MRI to study the retinotopic organization of the primary visual cortex (V1), and correlates visual defects with cortical thinning in V1 to characterize consequences of pituitary adenomas on the posterior visual system.

Methods: Eight patients (4 males and 4 females, mean age 44.3 years) with pituitary adenomas who exhibited chiasmatic compression and visual field defects, as well as 8 matched healthy controls (4 males and 4 females, mean age 43.3 years), were scanned at 7-T MRI for this prospective study. Whole-brain cortical thickness was calculated using an automated algorithm. A previously published surface-based algorithm was applied to associate the eccentricity and polar angle with each position in V1. Cortical thickness was calculated at each point in the retinotopic organization, and a cortical thickness ratio was generated against matched controls for each point in the visual fields. Patients with adenoma additionally underwent neuroophthalmological examination including 24-2 Humphrey automated visual field perimetry. Pattern deviation (PD) of each point in the visual field, i.e., the deviation in point detection compared with neurologically healthy controls, was correlated with cortical thickness at corresponding polar and eccentricity angles in V1.

Results: Whole-brain cortical thickness was successfully derived for all patients and controls. The mean tumor volume was 19.4 cm3. The median global thickness of V1 did not differ between patients (mean ± SD 2.21 ± 0.12 cm), compared with controls (2.06 ± 0.13 cm, p > 0.05). Surface morphometry-based retinotopic maps revealed that all 8 patients with adenoma showed a significant positive correlation between PD and V1 thickness ratios (r values ranged from 0.31 to 0.53, p < 0.05). Mixed-procedure analysis revealed that PD = -8.0719 + 5.5873*[Median V1 Thickness Ratio].

Conclusions: All 8 patients showed significant positive correlations between V1 thickness and visual defect. These findings provide retinotopic maps of localized V1 cortical neurodegeneration spatially corresponding to impairments in the visual field. These results further characterize changes in the posterior visual pathway associated with chiasmatic compression, and may prove useful in the neuroophthalmological workup for patients with pituitary macroadenoma.
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http://dx.doi.org/10.3171/2019.7.JNS191712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205160PMC
October 2019

Investigation of Skull-Based Cerebrospinal Fluid Leak Repair: A Single-Institution Comprehensive Study of 116 Cases Over 10 Years.

World Neurosurg 2020 Mar 8;135:e1-e11. Epub 2019 Oct 8.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Cerebrospinal fluid (CSF) leaks have been historically difficult to diagnose and treat because their cause can widely vary. There are insufficient diagnostic predictors and no clinically accepted standards for their treatment. This large institutional study reports on the diagnosis, management, and outcomes of patients presenting with CSF leak over 10 years and aims to identify potential comorbidities and risk factors for primary and recurrent leaks.

Methods: Patients diagnosed with CSF leak from 2007 to 2017 were analyzed retrospectively. The data included medical history, body mass index, surgical treatment, and postoperative outcomes.

Results: A total of 116 cases were identified. The location of leaks was 91 CSF rhinorrhea and 28 CSF otorrhea (3 both). The average BMI for females was greater than that of males (P = 0.01). Causes of leak were 64 noniatrogenic, 47 iatrogenic, and 9 traumatic. A total of 108 patients underwent surgical treatment. Sixty-nine were treated by endoscopic approaches, 42 involved open approaches, and 83 involved the placement of a lumbar drain. Eighteen patients had a ventriculoperitoneal shunt and 6 had a lumbar-peritoneal shunt. A total of 78 patients (72.22%) had an associated encephalocele with the CSF leak. The average length of stay was 7.73 days (0.76). The average length of follow-up was 1.58 years (0.22). The primary repair rate was 80.17% (n = 93) and the overall repair outcome was 99.14% (n = 115).

Conclusions: The overall CSF repair outcome was 99.14% over 10 years at a single institution. Despite this high percentage, CSF leaks continue to be a complex problem and require vigorous multidisciplinary work with close follow-up and use of multiple imaging strategies.
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http://dx.doi.org/10.1016/j.wneu.2019.09.133DOI Listing
March 2020

Emerging Therapeutic Targets in Chordomas: A Review of the Literature in the Genomic Era.

Neurosurgery 2020 02;86(2):E118-E123

Department of Neurosurgery, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, New York.

Chordomas are rare primary malignant tumors of the bones that occur along the skull base, spine, and sacrum. Long-term survival and neurological outcome continue to be challenging with continued low percentages of long-term survival. Recent studies have used genome, exome, transcriptome, and proteome sequencing to assess the mutational profile of chordomas. Most notably, Brachyury, or T-protein, has been shown to be an early mutational event in chordoma evolution. Clinically actionable mutations, including in the PI3K pathway, were identified. Preliminary evidence suggests that there may be mutational differences associated with primary tumor location. In this study, we review the therapeutic landscape of chordomas and discuss emerging targets in the genomic era.
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http://dx.doi.org/10.1093/neuros/nyz342DOI Listing
February 2020

Intravascular Papillary Endothelial Hyperplasia of the Maxillary Sinus in Patient with Tricuspid Atresia.

Head Neck Pathol 2020 Sep 31;14(3):803-807. Epub 2019 Aug 31.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Intravascular papillary endothelial hyperplasia (IPEH) is a benign, highly vascularized, endothelial growth that can be mischaracterized as a malignancy. While hundreds of IPEH cases are reported, only four occurred in the maxillary sinus. We present the case of a 28-year-old male who underwent surgical resection of IPEH of the right maxillary sinus. An additional consideration was the patient's condition of univentricular tricuspid atresia which contributed to chronic hypoxemia and polycythemia. After complete resection from the maxillary sinus, post-operational workup determined the lesion to be IPEH. Given the potential for misdiagnosis of IPEH, careful histopathologic evaluation is required in order to avoid improper treatment.
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http://dx.doi.org/10.1007/s12105-019-01070-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413958PMC
September 2020

First application of 7-T ultra-high field diffusion tensor imaging to detect altered microstructure of thalamic-somatosensory anatomy in trigeminal neuralgia.

J Neurosurg 2019 Aug 30:1-9. Epub 2019 Aug 30.

1Translational and Molecular Imaging Institute, and.

Objective: Trigeminal neuralgia (TN) is a debilitating neurological disease that commonly results from neurovascular compression of the trigeminal nerve (CN V). Although the CN V has been extensively studied at the site of neurovascular compression, many pathophysiological factors remain obscure. For example, thalamic-somatosensory function is thought to be altered in TN, but the abnormalities are inadequately characterized. Furthermore, there are few studies using 7-T MRI to examine patients with TN. The purpose of the present study was to use 7-T MRI to assess microstructural alteration in the thalamic-somatosensory tracts of patients with TN by using ultra-high field MRI.

Methods: Ten patients with TN and 10 age- and sex-matched healthy controls underwent scanning using 7-T MRI with diffusion tensor imaging. Structural images were segmented with an automated algorithm to obtain thalamus and primary somatosensory cortex (S1). Probabilistic tractography was performed between the thalamus and S1, and the microstructure of the thalamic-somatosensory tracts was compared between patients with TN and controls.

Results: Fractional anisotropy of the thalamic-somatosensory tract ipsilateral to the site of neurovascular compression was reduced in patients (mean 0.43) compared with side-matched controls (mean 0.47, p = 0.01). The mean diffusivity was increased ipsilaterally in patients (mean 6.58 × 10-4 mm2/second) compared with controls (mean 6.15 × 10-4 mm2/second, p = 0.02). Radial diffusivity was increased ipsilaterally in patients (mean 4.91 × 10-4 mm2/second) compared with controls (mean 4.44 × 10-4 mm2/second, p = 0.01). Topographical analysis revealed fractional anisotropy reduction and diffusivity elevation along the entire anatomical S1 arc in patients with TN.

Conclusions: The present study is the first to examine microstructural properties of the thalamic-somatosensory anatomy in patients with TN and to evaluate quantitative differences compared with healthy controls. The finding of reduced integrity of these white matter fibers provides evidence of microstructural alteration at the level of the thalamus and S1, and furthers the understanding of TN neurobiology.
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http://dx.doi.org/10.3171/2019.6.JNS19541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325446PMC
August 2019