Publications by authors named "Salah G Aoun"

101 Publications

Compressive Cervical Myelopathy in Patients With Demyelinating Disease of the Central Nervous System: Improvement After Surgery Despite a Late Diagnosis.

Cureus 2021 Feb 5;13(2):e13161. Epub 2021 Feb 5.

Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, USA.

Objective We aimed to assess the impact of surgical intervention on outcome in patients diagnosed with demyelinating disorders and cervical degenerative disease warranting surgical intervention. Methods The records of patients with a diagnosis of a demyelinating disorder of the central nervous system who underwent cervical spine surgery at a single institution from 2016 to 2020 were reviewed. Demyelinating disease included multiple sclerosis (MS), neuromyelitis optica, and transverse myelitis (TM). The dates of initial spine symptom onset, recognition of spinal pathology by the primary provider, referral to spine surgery, and spine surgery procedures were collected. Hospital length of stay (LOS) and postoperative outcomes and complications were recorded. Results A total of 19 patients with a diagnosis of demyelinating disorders underwent cervical spine surgery at our institution. Seventeen patients had MS. The average time interval between a documented diagnosis of myelopathy or radiculopathy and referral to the Spine clinic was 67.95 months (M=40, SD=64.87). Twelve patients had imaging studies depicting degenerative spine disease that would warrant surgical intervention at the time of examination by their primary physician. The average delay for referral to the Spine clinic for these patients was 16.5 months (M=5; SD=25.36). More than 89% of patients experienced significant neurologic improvement postoperatively. Conclusions There is a delay in the recognition of cervical spine disease amenable to a surgical resolution in patients with demyelinating disorders. Surgical treatment can lead to significant clinical improvement in this patient population even if delayed, and likely carries similar risk to that of the general population.
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http://dx.doi.org/10.7759/cureus.13161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935266PMC
February 2021

Delayed Cranial Nerve Palsies and Chiari Type I Malformation After Epidural Anesthesia in the Setting of Childbirth.

Cureus 2021 Jan 23;13(1):e12871. Epub 2021 Jan 23.

Neurosurgery, University of Texas Southwestern Medical Center, Dallas, USA.

Epidural analgesia is an efficient method of controlling pain and has a wide spectrum of therapeutic and diagnostic applications. Potential complications may occur in a delayed fashion, can remain undiagnosed, and can be a source of significant morbidity. We present a 37-year-old woman presented with severe spontaneous occipital headaches, diplopia, and dizziness that occurred spontaneously six weeks after giving birth. Her primary method of pain control during labor was epidural analgesia. Her neurologic exam revealed a cranial nerve six palsy with ptosis, and her brain MRI demonstrated a Chiari I malformation which had not been previously diagnosed. CT myelography of the lumbar spine revealed extradural contrast extravasation within the interspinous soft tissue at L1-L2, which was the site of her prior epidural procedure. She underwent epidural blood patch administration, and her cranial nerve palsy resolved along with all of her other symptoms. The development of concurrent Chiari I malformation and cranial nerve palsy after epidural anesthesia is an exceptionally rare occurrence. Neurologic complications after epidural anesthesia are likely under-reported, since patients are often lost to follow-up or have subtle neurologic signs which can easily be missed. This frequently delayed presentation emphasizes the importance of patient education and the necessity of a detailed neurological exam when symptoms occur.
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http://dx.doi.org/10.7759/cureus.12871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899279PMC
January 2021

Evaluating the Impact of Psychiatric Disorders on Preoperative Pain Ratings, Narcotics Use, and the PROMIS-29 Quality Domains in Spine Surgery Candidates.

Cureus 2021 Jan 18;13(1):e12768. Epub 2021 Jan 18.

Neurosurgery, University of Texas Southwestern Medical Center, Dallas, USA.

Objective We aimed to study the relationship between psychiatric Disorders (PD), preoperative pain, and opioid medication intake, as well as the quality of life patient-reported outcome measures using the Patient-Reported Outcomes Measurement Information System 29 (PROMIS-29) questionnaire, during the 30-day interval preceding surgery, in a consecutive series of patients who were scheduled to undergo surgical spine procedures. We hypothesized that PD could affect preoperative narcotic use and pain interference in a fashion that was not linearly associated with preoperative pain in spine surgery candidates. Methods The records of consecutive adult patients who underwent elective spinal surgery between October 2016 and August 2017 at a single institution were reviewed. We included patients who underwent preoperative pain assessment within 30 days prior to their planned surgery using the PROMIS-29 questionnaire. Patients with PD were compared to controls. Results A total of 117 patients matched our criteria. The average rating of pain intensity was notably higher in the PD group as compared to controls (p=0.004). The PD group had more patients complaining of high pain levels (>6) as compared to the control group (p=0.026). Controls with high pain levels had a greater incidence of preoperative narcotic use as compared to the low-pain cohort (p=0.029). However, there was no difference in the actual dose of daily narcotic medication taken between the PD and control groups (P=0.099) or between the low- and high pain score groups in the control (p=0.291) and PD (p=0.441) groups, respectively. Patients with PD and higher pain ratings seemed to have a higher incidence of anxiety (p=0.005) and depression (p<0.001). That was not the case for controls. Conclusions PDs may impact the degree of preoperative pain interference and the intake of narcotic medication independently from pain intensity ratings.
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http://dx.doi.org/10.7759/cureus.12768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888361PMC
January 2021

Microwave Ablation as a Treatment for Spinal Metastatic Tumors: A Systematic Review.

World Neurosurg 2021 Apr 8;148:15-23. Epub 2021 Jan 8.

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Background: Microwave ablation (MWA) is a novel technique that offers several potential advantages over existing ablation systems, which include production of larger ablation zones, shorter procedural times, and more effective heating through high impedance tissues such as bone.

Methods: A systematic review was performed using inclusion criteria defined as follows: 1) metastatic spinal tumors treated with open or percutaneous MWA alone or in combination with other treatments, 2) available data on pain palliation and/or local tumor control, and 3) retrospective or prospective studies with at least 1 patient.

Results: A total of 156 patients harboring 196 spinal lesions underwent MWA in the 8 included studies. Most studies employed the use of additional interventions, which included minimally invasive open surgery with pedicle screw fixation, traditional open surgical intervention, and cement augmentation. Despite the variability in time intervals for pain assessment, postoperative pain scores decreased considerably in both percutaneous and open MWA studies. No evidence of tumor progression was additionally seen in >80% of patients at the last follow-up across 5 studies. Complications were reported in 6.5% of all patients who underwent percutaneous MWA and in 12.2% of patients who underwent open MWA.

Conclusions: This review showed that MWA can be effective in achieving analgesia for up to 6 months in select cases, although most procedures were performed in combination with augmentation and/or open surgery. Local tumor control was additionally successful in most patients, suggestive of a potential curative role for MWA.
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http://dx.doi.org/10.1016/j.wneu.2020.12.162DOI Listing
April 2021

Perioperative Optimization of Senior Health in Spine Surgery: Impact on Postoperative Delirium.

J Am Geriatr Soc 2020 Dec 31. Epub 2020 Dec 31.

Department of Internal Medicine, Geriatrics Division, UT Southwestern Medical School, Dallas, Texas, USA.

Background: Delirium is a common postoperative complication in geriatric patients, especially in those with underlying risk factors. Multicomponent nonpharmacologic interventions are effective in preventing delirium, however, implementation of these measures is variable in perioperative care. The aim of our study was to assess the impact of our Perioperative Optimization of Senior Health Program (UTSW POSH) on postoperative delirium in patients undergoing elective spine surgery.

Study Design: The UTSW POSH program is an interdisciplinary perioperative initiative involving geriatrics, surgery, and anesthesiology to improve care for high-risk geriatric patients undergoing elective spine surgery. Preoperatively, enrolled patients (n = 147) were referred for a geriatric assessment and optimization for surgery. Postoperatively, patients were co-managed by the primary surgical team and the geriatrics consult service. UTSW POSH patients were retrospectively compared to a matched historical control group (n = 177) treated with usual care. Main outcomes included postoperative delirium and provider recognition of delirium.

Results: UTSW POSH patients were significantly older (75.5 vs 71.5 years; P < .001), had more comorbidities (8.02 vs 6.58; P < .001), and were more likely to undergo pelvic fixation (36.1% vs 17.5%; P < .001). The incidence of postoperative delirium was lower in the UTSW POSH group compared to historical controls, although not statistically significant (11.6% vs 19.2%; P = .065). Delirium was significantly lower in patients who underwent complex spine surgery (≥4 levels of vertebral fusion; N = 106) in the UTSW POSH group (11.7% vs 28.9%, P = .03). There was a threefold increase in the recognition of postoperative delirium by providers after program implementation, (76.5% vs 23.5%; P = .001).

Conclusions: This study suggests that interdisciplinary care for high-risk geriatric patients undergoing elective spine surgery may reduce the incidence of postoperative delirium and increase provider recognition of delirium. The benefit may be greater for those undergoing larger procedures.
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http://dx.doi.org/10.1111/jgs.17006DOI Listing
December 2020

Comparison of the effect of epidural versus intravenous patient controlled analgesia on inpatient and outpatient functional outcomes after adult degenerative scoliosis surgery: a comparative study.

Spine J 2020 Dec 23. Epub 2020 Dec 23.

Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA; Department of Orthopedic Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA.

Background: Perioperative pain can negatively impact patient recovery after spine surgery and be a contributing factor to increased hospital length of stay and cost. Most data currently available is extrapolated from adolescent idiopathic cases and may not apply to adult and geriatric populations with thoracolumbar spine degeneration.

Purpose: Study the impact of epidural analgesia on pain control and outcomes after adult degenerative scoliosis surgery in a large single-institution series of adult patients undergoing thoraco-lumbar-pelvic fusion.

Study Design/setting: Retrospective single-center review of prospectively collected data.

Patient Sample: Patients undergoing thoracolumbar fusion with pelvic fixation.

Outcome Measures: Self-reported measures: Visual analog scale for pain. Physiologic Measures: Oral pain control requirements converted into daily morphine equivalents. Functional Measures: Ambulation perimeter after surgery, urinary retention and constipation rates.

Methods: We retrospectively reviewed patient data for the years 2016 and 2017 before the use of Patient Controlled epidural Analgesia (PCEA), and then 2018 and 2019 after its implementation, for all thoracolumbar degenerative procedures, and compared their postoperative outcomes measures.

Results: There were 46 patients in the PCEA group and 37 patients in the intravenous PCA (IVPCA) groups. All patients underwent long segment posterolateral thoracolumbar spinal fusion with pelvic fixation. Patients in the PCEA group had lower pain scores and ambulated greater distances compared with those in the IVPCA group. PCEA patients also had lower urinary retention and constipation rates, but no increased intraoperative or postoperative complications related to catheter placement.

Conclusions: PCEA can provide optimal pain control after adult degenerative scoliosis spine surgery, and may promote greater early ambulation, while decreasing postoperative constipation and urinary retention rates.
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http://dx.doi.org/10.1016/j.spinee.2020.12.005DOI Listing
December 2020

Commentary: Hemifacial Spam: Endoscopic Assistance in Facial Nerve Decompression With Lateral Spread Response Corroboration: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Jan;20(2):E129-E130

Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas.

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http://dx.doi.org/10.1093/ons/opaa387DOI Listing
January 2021

Bertolotti Syndrome With Articulated L5 Transverse Process Causing Intractable Back Pain: Surgical Video Showcasing a Minimally Invasive Approach for Disconnection: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Feb;20(3):E219-E220

Department of Neurological Surgery, The University of Texas Southwestern, Dallas, Texas.

Bertolotti syndrome is a commonly missed cause of intractable back pain that affects 4% to 8% of the general population. It involves the congenital malformation of a transitional lumbosacral vertebra, with total or partial and unilateral or bilateral transverse process (TP) fusion or articulation to the sacrum. The pain can be debilitating, and the tethering of the spine to the sacrum can encourage deformity formation in the coronal plane and lead to early degenerative changes, especially if present only unilaterally. We present the case of a 24-yr-old woman with no notable prior medical history who presented with years of lower axial back pain radiating to her thighs, which limited her activities of daily living and was resistant to conservative management. Her imaging showed an abnormally large left L5 TP, which was articulated to the sacrum, and signs of early coronal deformity. She had responded almost completely to repeated steroid injections into the TP-sacral joint, but that effect was very transient. Informed patient consent was obtained prior to her surgery. She underwent a minimally invasive tube disconnection of the abnormal joint with partial distal resection of the TP, and her symptoms completely resolved. This case highlights the importance of correlating clinical symptoms with aberrant anatomy, and the role of selective surgery in providing symptomatic relief. This case report was written in compliance with our institutional ethical review board approval, and patient consent was waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas Southwestern institutional review board.
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http://dx.doi.org/10.1093/ons/opaa343DOI Listing
February 2021

Smoking has a dose-dependent effect on the incidence of preoperative opioid consumption in female geriatric patients with spine disease.

J Clin Neurosci 2020 Nov 10;81:173-177. Epub 2020 Oct 10.

UT Southwestern Medical Center, Department of Neurological Surgery, United States; UT Southwestern Medical Center, Department of Orthopedic Surgery, United States; UT Southwestern Spine Center, United States.

Tobacco use and narcotic medication have been associated with worse functional outcomes after surgery. Our goal was to investigate potential associations between smoking and preoperative opioid consumption in a geriatric population undergoing spine surgery, and their impact on postoperative outcomes. The records of 536 consecutive patients aged more than 65 years who underwent elective spinal surgery between November 2014 and August 2017 at a single institution were reviewed. Primary outcomes included rates of preoperative opioid consumption and postoperative hospital length of stay and complications. Males were more likely to be smokers than females (p < 0.001), whereas females were more likely to take opioid analgesics preoperatively (p = 0.022). Women with a history of smoking were more likely to have increased preoperative opioid consumption compared to those with no history of smoking (63.64% vs. 42.04%; p < 0.001). Such a relationship was not found in men. Subgroups analysis of female patients with a history of tobacco use comparing current and former smoker status showed that both groups exhibited increased preoperative opioid consumption compared to patients who never smoked (88.89% vs 42.04%; p < 0.001 for current users; 59.42% vs 42.04% for former users; p = 0.008). There was also a dose-depended relationship between smoking and increased preoperative opioid consumption. Geriatric female spine patients with a history of smoking have a higher incidence of preoperative opioid consumption. Opioid intake appears to increase with the number of pack-years, both in patients with a history of smoking and in those who currently smoke.
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http://dx.doi.org/10.1016/j.jocn.2020.09.066DOI Listing
November 2020

Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury.

World Neurosurg 2021 Jan 2;145:e163-e169. Epub 2020 Oct 2.

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA. Electronic address:

Objective: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. Automated infrared pupillometry (AIP) has shown promising results in predicting neural damage in aneurysmal subarachnoid hemorrhage and ischemic stroke. We aimed to explore potential uses of AIP in triaging patients with TBI. We hypothesized that a brain injury severe enough to require an intervention would show Neurologic Pupil Index (NPI) changes.

Methods: We conducted a prospective pilot study at a level-1 trauma center between November 2019 and February 2020. AIP readings of consecutive patients seen in the emergency department with blunt TBI and abnormal imaging findings on computed tomography were recorded by the assessing neurosurgery resident. The relationship between NPI and surgical intervention was studied.

Results: Thirty-six patients were enrolled, 9 of whom received an intervention. NPI was dichotomized into normal (≥3) versus abnormal (<3) and was predictive of intervention (Fisher exact test; P < 0.0001). Six of the 9 patients had a Glasgow Coma Scale (GCS) score ≤8 and imaging signs of increased intracranial pressure (ICP) and underwent craniectomy (n = 4) or ICP monitor placement (n = 2) and had an abnormal NPI. Three patients underwent ICP monitor placement for GCS score ≤8 in accordance with TBI guidelines despite minimal imaging findings and had a normal NPI. The GCS score of these patients improved within 24 hours, requiring ICP monitor removal. NPI was normal in all patients who did not require intervention.

Conclusions: AIP could be useful in triaging comatose patients after blunt TBI. An NPI ≥3 may be reassuring in patients with no signs of mass effect or increased ICP.
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http://dx.doi.org/10.1016/j.wneu.2020.09.152DOI Listing
January 2021

Enhanced Recovery After Surgery Reduces Postoperative Opioid Use and 90-Day Readmission Rates After Open Thoracolumbar Fusion for Adult Degenerative Deformity.

Neurosurgery 2021 01;88(2):295-300

Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas.

Background: The role of enhanced recovery after surgery (ERAS) pathways implementation has not been previously explored in adult deformity patients.

Objective: To determine the impact of ERAS pathways implementation in adult patients undergoing open thoraco-lumbar-pelvic fusion for degenerative scoliosis on postoperative outcome, opioid consumption, and unplanned readmission rates.

Methods: In this retrospective single-center study, we included 124 consecutive patients who underwent open thoraco-lumbar-pelvic fusion from October 2016 to February 2019 for degenerative scoliosis. Primary outcomes consisted of postoperative supplementary opioid consumption in morphine equivalent dose (MED), postoperative complications, and readmission rates within the postoperative 90-d window.

Results: There were 67 patients in the ERAS group, and 57 patients served as pre-ERAS controls. Average patient age was 69 yr. The groups had comparable demographic and intraoperative variables. ERAS patients had a significantly lower rate of postoperative supplemental opioid consumption (248.05 vs 314.05 MED, P = .04), a lower rate of urinary retention requiring catheterization (5.97% vs 19.3%, P = .024) and of severe constipation (1.49% vs 31.57%, P < .0001), and fewer readmissions after their surgery (2.98% vs 28.07%, P = .0001).

Conclusion: A comprehensive multidisciplinary approach to complex spine surgery can reduce opioid intake, postoperative urinary retention and severe constipation, and unplanned 90-d readmissions in the elderly adult population.
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http://dx.doi.org/10.1093/neuros/nyaa399DOI Listing
January 2021

Recent advances in understanding and managing chordomas: an update.

F1000Res 2020 16;9. Epub 2020 Jul 16.

Department of Neurological Surgery, University of Texas Southwestern School of Medicine, Dallas, TX, USA.

Chordomas are rare and difficult-to-treat tumors arising from the embryonic notochord. While surgery is the mainstay of treatment, and despite new techniques aimed at maximizing total tumoral resection, recurrence remains high and the probability of disease-free survival low. New breakthroughs in genetics, targeted molecular therapy, and heavy-particle beam therapy offer some promise as adjuvant treatments in addition to surgical resection. A multidisciplinary approach encompassing genetics, immunotherapy, radiation therapy, and surgery, at a facility experienced in the management of this complex disease, offers the best chance of survival and quality of life to patients while limiting the intrinsic morbidity of these treatments.
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http://dx.doi.org/10.12688/f1000research.22440.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366033PMC
October 2020

Extraneural metastatic anaplastic ependymoma: a systematic review and a report of metastases to bilateral parotid glands.

Neurooncol Pract 2020 Mar 1;7(2):218-227. Epub 2019 Nov 1.

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas.

Background: Anaplastic ependymoma with extraneural metastases is associated with a poor clinical outcome. Metastatic spread to the parotid gland is a rare clinical entity that requires multidisciplinary intervention. Herein, we present a systematic review of anaplastic ependymoma with extraneural metastases and report on a case with metastases to both parotid glands.

Methods: Electronic databases were searched from their inception to February 2019. Inclusion criteria included reports of anaplastic ependymoma with extraneural metastasis. Studies were excluded if the tumor grade was not reported. A case illustration is provided.

Results: The search yielded 15 cases of anaplastic ependymoma with extraneural metastases, including the present case. Mean age at diagnosis was 15 years. The initial tumor location was predominantly supratentorial (93.3%). All cases demonstrated leptomeningeal seeding before extraneural metastasis. Mean survival from initial diagnosis was 4.5 years. Metastasis to the parotid gland occurred in 2 cases, including the present case. We present a 17-year-old female patient who underwent gross total resection of a supratentorial, paraventricular anaplastic ependymoma followed by adjuvant external beam radiation therapy. The patient developed recurrent leptomeningeal seeding, treated with Gamma Knife radiosurgery over a 5-year period. She returned with a parotid mass and cervical lymphadenopathy and underwent parotidectomy and modified radical neck dissection. She continued to experience recurrences, including the left parotid gland, and was ultimately placed in hospice care.

Conclusions: Anaplastic ependymoma with extraneural metastasis is rare. A combination of repeated surgical resection, radiation therapy, and chemotherapy can be used to manage recurrent and metastatic disease, but outcomes remain poor.
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http://dx.doi.org/10.1093/nop/npz041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318859PMC
March 2020

Electronic Communication Patterns Could Reflect Preoperative Anxiety and Serve as an Early Complication Warning in Elective Spine Surgery Patients with Affective Disorders: A Retrospective Analysis of a Cohort of 1199 Elective Spine Patients.

World Neurosurg 2020 09 17;141:e888-e893. Epub 2020 Jun 17.

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Objective: The analysis of perioperative electronic patient portal (EPP) communication may provide risk stratification and insight for complication prevention in patients with affective disorders (ADs). We aimed to understand how patterns of EPP communication in patients with AD relate to preoperative narcotic use, surgical outcomes, and readmission rates.

Methods: The records of adult patients who underwent elective spinal surgery between January 2010 and August 2017 at a single institution were retrospectively reviewed for analysis. Primary outcomes included preoperative narcotic use, the number of perioperative EPP messages sent, rates of perioperative complications, hospital length of stay, emergency department (ED) visits within 6 weeks, and readmissions within 30 days after surgery.

Results: A total of 1199 patients were included in the analysis. Patients with an AD were more likely to take narcotics before surgery (51.69% vs. 41%, P < 0.001) and to have active EPP accounts (75.36% vs. 69.75%, P = 0.014) compared with controls. They were also more likely to send postoperative messages (38.89% vs. 32.75%, P = 0.030) and tended to send more messages (0.67 vs. 0.48, P = 0.034). The AD group had higher rates of postoperative complications (8.21% vs. 3.98%, P = 0.001), ED visits (4.99% vs. 2.43%, P = 0.009), and readmissions postoperatively (2.49% vs. 1.38%, P = 0.049).

Conclusions: AD patients have specific patterns of perioperative EPP communication. They are at a higher risk of postoperative complications. Addressing these concerns early may prevent more serious morbidity and avoid unnecessary ED visits and readmissions, thus reducing costs and improving patient care.
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http://dx.doi.org/10.1016/j.wneu.2020.06.082DOI Listing
September 2020

Does endovascular therapy change outcomes in nonagenarians with acute ischemic stroke?

J Clin Neurosci 2020 Aug 13;78:207-210. Epub 2020 May 13.

Department of Neurological Surgery, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390, USA; Department of Neurology and Neurotherapeutics, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390, USA. Electronic address:

Background: Ischemic strokes can be devastating for elderly patients, and randomized control trials of mechanical thrombectomy have shown encouraging results. We present the first analysis of clinical outcomes in nonagenarians with acute ischemic stroke treated with best medical therapy compared to endovascular revascularization therapy.

Methods: A retrospective analysis was performed on 42 patients 90 years or older who were treated for acute ischemic stroke. Modified Rankin scores were calculated immediately post-injury, at discharge, and at 30 days and 90 days following discharge. Student's t-test and Wald tests were performed to evaluate whether endovascular treatment was associated with modified Rankin Score improvement at discharge, 30 days, or 90 days after discharge.

Results: Follow-up data were available for 32/42 (76%) and 20/42 (48%) patients at 30 and 90 days after discharge, respectively. 8/9 (89%) patients who underwent endovascular treatment reached Thrombolysis in Cerebral Infarction scale 2b or better with no procedural complications. 12/42 (29%) patients, including four who underwent endovascular treatment, were discharged to hospice or deceased. No significant differences in modified Rankin Score improvement were observed between the endovascular and medical management groups at discharge (p = 0.96), at 30 days (p = 0.63), or at 90 days (p = 0.96).

Conclusions: Our analysis shows that revascularization therapy is a safe treatment, but it was not associated with improved functional status in nonagenarians with acute ischemic stroke. Endovascular therapy shows promise, and larger prospective studies are necessary to assess the benefits of revascularization therapy in the elderly population.
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http://dx.doi.org/10.1016/j.jocn.2020.04.060DOI Listing
August 2020

Systematic Review and Meta-Analysis of Management Strategies and Outcomes in Adult Spinal Neurocysticercosis.

World Neurosurg 2020 06 27;138:504-511.e8. Epub 2020 Mar 27.

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Objective: Spinal involvement in neurocysticercosis is rare and can lead to debilitating injury if not diagnosed and treated early. We aim to provide the reader with a thorough analysis of the best available evidence regarding patient characteristics, optimal treatment modality, and outcomes in cases of spinal neurocysticercosis.

Methods: A systematic review of the literature using PubMed, Google Scholar, and Web of Science electronic databases was made according to the PRISMA guidelines. An illustrative case of intramedullary-cervical spinal disease is also presented for illustrative purposes.

Results: A total of 46 reports of 103 patients fitting the screening criteria were identified. Isolated spinal involvement was seen in 46.15% of patients. Most infections (76.92%) had an intradural extramedullary localization, with 43.27% of cases involving >1 spinal cord level. The most common presenting symptoms were motor deficits (77.88%), pain syndromes (64.42%), and sensory deficits (53.85%). Combined surgical resection and pharmacologic therapy was the most frequently used treatment modality (49.04%) and had the highest proportion of patients reporting symptomatic improvement at follow-up (78.43%). Combination therapy had a significantly higher rate of neurologic recovery compared with surgery alone (P = 0.004) or medical treatment (P = 0.035).

Conclusions: Spinal involvement in neurocysticercosis should be considered in patients from or who traveled to endemic areas presenting with ring-enhancing lesions. Combined treatment with surgery followed by cysticidal and steroid medication seems to be superior to surgery or medical treatment in isolation and seems to provide the highest chances of recovery.
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http://dx.doi.org/10.1016/j.wneu.2020.03.093DOI Listing
June 2020

The Hydrogel Endovascular Aneurysm Treatment Trial (HEAT): A Randomized Controlled Trial of the Second-Generation Hydrogel Coil.

Neurosurgery 2020 05;86(5):615-624

Department of Neurological Surgery Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky.

Background: Aneurysm recurrence after coiling has been associated with aneurysm growth, (re)hemorrhage, and a greater need for follow-up. The second-generation HydroCoil Embolic System (HES; MicroVention, Inc) consists of a platinum core with integrated hydrogel and was developed to reduce recurrence through enhancing packing density and healing within the aneurysm.

Objective: To compare recurrence between the second-generation HES and bare platinum coil (BPC) in the new-generation Hydrogel Endovascular Aneurysm Treatment Trial (HEAT).

Methods: HEAT is a randomized, controlled trial that enrolled subjects with ruptured or unruptured 3- to 14-mm intracranial aneurysms amenable to coiling. The primary endpoint was aneurysm recurrence using the Raymond-Roy scale. Secondary endpoints included minor and major recurrence, packing density, adverse events related to the procedure and/or device, mortality, initial complete occlusion, aneurysm retreatment, hemorrhage from target aneurysm during follow-up, aneurysm occlusion stability, and clinical outcome at final follow-up.

Results: A total of 600 patients were randomized (HES, n = 297 and BPC, n = 303), including 28% with ruptured aneurysms. Recurrence occurred in 11 (4.4%) subjects in the HES arm and 44 (15.4%) subjects in the BPC arm (P = .002). While the initial occlusion rate was higher with BPC, the packing density and both major and minor recurrence rates were in favor of HES. Secondary endpoints including adverse events, retreatment, hemorrhage, mortality, and clinical outcome did not differ between arms.

Conclusion: Coiling of small-to-medium aneurysms with second-generation HES resulted in less recurrence when compared to BPC, without increased harm. These data further support the use of the second-generation HES for the embolization of intracranial aneurysms.

Video Abstract:
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http://dx.doi.org/10.1093/neuros/nyaa006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534546PMC
May 2020

The effectiveness of tranexamic acid on operative and perioperative blood loss in long-segment spinal fusions: a consecutive series of 119 primary procedures.

J Neurosurg Spine 2020 Jan 24:1-7. Epub 2020 Jan 24.

Departments of1Neurological Surgery and.

Objective: The aim of this study was to determine if the use of tranexamic acid (TXA) in long-segment spinal fusion surgery can help reduce perioperative blood loss, transfusion requirements, and morbidity.

Methods: In this retrospective single-center study, the authors included 119 consecutive patients who underwent thoracolumbar fusion spanning at least 4 spinal levels from October 2016 to February 2019. Blood loss, transfusion requirements, perioperative morbidity, and adverse thrombotic events were compared between a cohort receiving intravenous TXA and a control group that did not.

Results: There was no significant difference in any measure of intraoperative blood loss (1514.3 vs 1209.1 mL, p = 0.29) or transfusion requirement volume between the TXA and control groups despite a higher number of pelvic fusion procedures in the TXA group (85.9% vs 62.5%, p = 0.003). Postoperative transfusion volume was significantly lower in TXA patients (954 vs 572 mL, p = 0.01). There was no difference in the incidence of thrombotic complications between the groups.

Conclusions: TXA appears to provide a protective effect against blood loss in long-segment spine fusion surgery specifically when pelvic dissection and fixation is performed. TXA also seems to decrease postoperative transfusion requirements without increasing the risk of adverse thrombotic events.
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http://dx.doi.org/10.3171/2019.11.SPINE191174DOI Listing
January 2020

The Use of 5-Aminolevulinic Acid in Low-Grade Glioma Resection: A Systematic Review.

Oper Neurosurg (Hagerstown) 2020 07;19(1):1-8

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

Background: For optimizing high-grade glioma resection, 5-aminolevulinic acid is a reliable tool. However, its efficacy in low-grade glioma resection remains unclear.

Objective: To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and the effect on the extent of resection.

Methods: A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. The quality index of the selected papers was provided. No patient information was used, so Institutional Review Board approval and patient consent were not required.

Results: A total of 12 articles met the selection criteria with 244 histologically confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n = 60/244; 24.5%) demonstrated visual intraoperative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies; however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10-17), which correlated with an overall good quality.

Conclusion: There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.
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http://dx.doi.org/10.1093/ons/opz336DOI Listing
July 2020

Resection of a Symptomatic Dysplastic Cerebellar Gangliocytoma: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 08;19(2):E178

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.

Lhermitte-Duclos disease, also known as dysplastic cerebellar gangliocytoma, is a rare benign cerebellar tumor that is typically observed but may occasionally become symptomatic and requires surgical intervention. The condition is caused by a mutation in the phosphatase and tensin homolog (PTEN) gene, which results in dysregulation of the mammalian target of rapamycin pathway. A germline PTEN mutation results in multi-organ involvement and is termed Cowden syndrome. There is a scarcity of surgical videos in the published literature that demonstrate an intraoperative resection of this lesion and illustrate the pathology in Vivo. We present an operative video of a surgical resection of a symptomatic dysplastic cerebellar gangliocytoma in a 44-yr-old male patient who presented with a 3-mo history of progressive headaches and hydrocephalus. The patient underwent an endoscopic third ventriculostomy and, subsequently, a right suboccipital craniotomy for microsurgical resection of the mass. The procedure was performed with the patient in the lateral position. The microscope was positioned at the head of the bed and the stereotaxic system monitor on the patient's left side. The patient tolerated the procedure well and imaging obtained at 18 mo was negative for residual or recurrent disease. The patient gave written consent for video recording as part of the surgery informed consent. No identifiable images or video footage of the face are shown, and institutional review board approval was deemed unnecessary.
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http://dx.doi.org/10.1093/ons/opz346DOI Listing
August 2020

Intramedullary Spinal Metastatic Renal Cell Carcinoma: Systematic Review of Disease Presentation, Treatment, and Prognosis with Case Illustration.

World Neurosurg 2020 Feb 14;134:584-593. Epub 2019 Nov 14.

Department of Neurological Surgery, University of Texas Southwestern, Dallas, Texas, USA.

Objective: Renal cell carcinoma (RCC) metastases to the intramedullary spinal cord carry a grim prognosis. The purpose of this review is to provide the reader with a comprehensive and systematic review of the current literature, and to present an illustrative case that would aid in the future management of similar scenarios.

Methods: A systematic review of the literature using the PubMed electronic database was made according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only human clinical reports of intramedullary RCC metastasis were included. We also present an illustrative case that was treated at our institution.

Results: We identified 23 reports with a total of 31 patients. Of the tumors, 47% were located at the cervical level. Brain metastases were present in 41% of cases. Limb weakness (72%), urinary incontinence (41%), dysesthesia (47%), and localized spinal pain (38%) were the most frequently reported symptoms. Surgical resection alone was used in 34% of cases, followed by a combination of surgery and radiotherapy (31%), and radiotherapy alone (25%). Spinal metastases were detected an average of 32.1 months after the diagnosis of RCC, and mean patient survival after that was 8 months (range, 0-65 months). Reported survival after radiotherapy appeared to be the longest (11.2 months) compared with surgery (9.1 months) and combination therapy (5 months).

Conclusions: Intramedullary spinal metastatic RCC is a rare entity with debilitating neurologic potential. Survival appears to be affected by the treatment method but is also likely influenced by the stage of discovery of the disease.
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http://dx.doi.org/10.1016/j.wneu.2019.11.056DOI Listing
February 2020

Retrieval of an Intracranially Migrated Dental Injection Needle Through the Foramen Ovale: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 08;19(2):E168

Department of Neurological Surgery, The University of Texas Southwestern, Dallas, Texas.

Dental injection needle migration is a rare complication of orthodontal procedures. When these needles fracture, they typically dislodge into the cervical space or the facial musculature. Migration into the cranial vault is difficult because of the obstacle created by the skull base. We report a rare case of intracranial migration of an anesthetic injection needle through the foramen ovale. A 59-yr-old man underwent the extraction of a right maxillary molar. The distal end of a 25-gauge injection needle broke into his pterygoid musculature, causing him pain while chewing. Vascular imaging obtained after a computed tomography scan of his face showed that the needle had migrated, potentially because of his efforts of mastication, and had traversed the foramen ovale into the middle cranial fossa. The patient started experiencing intermittent right facial numbness, likely due to compression or injury to the right trigeminal nerve. Our oral and maxillofacial colleagues did not believe that the needle could be retrieved from its facial end. The patient elected to undergo the recovery of the needle through a craniotomy given the fact that the object was contaminated and because he was becoming increasingly symptomatic. A right pterional craniotomy was planned. Extradural dissection was performed until the dura going into the foramen ovale was revealed. We could feel the metallic needle under the dural sheath of the trigeminal nerve. The dura was opened sharply directly over the needle. We then proceeded to mobilize the needle into the face, and then pulled it out completely through the craniotomy to avoid injury to the temporal lobe. The patient recovered well and was asymptomatic at the time of discharge. This case report was written in compliance with our institutional ethical review board. Institutional review board (IRB) approval and patient consent were waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas Southwestern (UTSW) IRB.
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http://dx.doi.org/10.1093/ons/opz329DOI Listing
August 2020

Tumoral Mimics of Subdural Hematomas: Case Report and Review of Diagnostic and Management Strategies in Primary B-Cell Lymphoma of the Subdural Space.

World Neurosurg 2020 Jan 25;133:49-54. Epub 2019 Sep 25.

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Background: Subdural lymphomas are a rare subtype of primary central nervous system lymphomas that can radiographically mimic epidural blood and pose a diagnostic challenge. They can complicate treatment if not preemptively identified.

Methods: We present a case report of a subdural lymphoma that mimicked a compressive subdural hematoma, and we review the PubMed database for similar cases.

Results: A 77-year-old woman presented with a transient left facial droop and what appeared to be a subdural hematoma on computed tomography scan. The patient underwent surgery, during which grossly abnormal solid epicortical adherent tissue was noted instead of the expected appearance of a subdural hematoma. An intraoperative biopsy was suggestive of lymphoma, and the surgery was converted to a craniectomy. Pathology confirmed the diagnosis of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue. The patient underwent radiotherapy with no complications or recurrence. Magnetic resonance imaging demonstrated complete resolution of the mass at 3 months after treatment, at which time the patient underwent a synthetic cranioplasty. Seven case reports of primary dural lymphomas mimicking subdural blood were found, with variable pathologic subclassifications.

Conclusions: Although rare, a primary dural lymphoma can be mistaken for a subdural hematoma on computed tomography scan. The most common subtype is low-grade extranodal marginal zone lymphomas. It is important to keep these diseases in the differential diagnosis, especially when there is incongruence between imaging and the clinical picture, as earlier detection correlates to a stronger therapeutic response.
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http://dx.doi.org/10.1016/j.wneu.2019.09.091DOI Listing
January 2020

Minimally Invasive Endoscopic Aspiration of a Spinal Epidural Dermoid Cyst Extending From T10 to the Sacrum: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 May;18(5):E172

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.

Dermoid cysts are space-occupying tumors that can occur anywhere in the neuroaxis. Although categorized as benign lesions, they can compromise normal structures, causing neurological function loss, and have a tendency to recur often requiring repeated surgical resections. We illustrate the case of an extensive epidural dermoid cyst in a 22-yr-old woman who presented with progressive loss of neurological motor function in her lower extremities as well as bowel and bladder incontinence. The tumor extended from T10 to the sacrum, and a conventional operation would have entailed serial laminectomies that would cross the thoracolumbar and lumbosacral junctions, possibly requiring an instrumented fusion. Given the fact that operation would have carried significant morbidity, especially with the high likelihood of symptomatic tumoral recurrence, we consulted with our urology colleagues to find a minimally invasive way of reducing the tumor burden and decompressing the neural elements. The patient was taken to the operating room and a limited open lumbosacral durotomy was performed. A flexible cystoscope was then passed in the epidural space and used to suction the tumor. Postoperative imaging showed adequate resection, and the patient recovered neurological function completely. She had mini-mal recurrence at 3 yr and remained asymptomatic. This technical video note showcases the potential for use of endoscopy for spine tumors that have an amenable consistency, even in highly eloquent areas such as the conus medullaris. It also serves to highlight the benefits of interdisciplinary cooperation when treating complex disease. This case report was written in compliance with our institutional ethical review board. Institutional Review Board (IRB) approval and patient consent was waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas SouthWestern IRB. Patient consent was waived for writing this manuscript in light of the retrospective and deidentified nature of the data presented in accordance with our institutional IRB.
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http://dx.doi.org/10.1093/ons/opz237DOI Listing
May 2020

Stem cell injections for axial back pain: a systematic review of associated risks and complications with a case illustration of diffuse hyperplastic gliosis resulting in cauda equina syndrome.

J Neurosurg Spine 2019 Sep 6:1-8. Epub 2019 Sep 6.

1Departments of Neurological Surgery and.

Objective: Axial low-back pain is a disease of epidemic proportions that exerts a heavy global toll on the active workforce and results in more than half a trillion dollars in annual costs. Stem cell injections are being increasingly advertised as a restorative solution for various degenerative diseases and are becoming more affordable and attainable by the public. There have been multiple reports in the media of these injections being easily available abroad outside of clinical trials, but scientific evidence supporting them remains scarce. The authors present a case of a serious complication after a stem cell injection for back pain and provide a systematic review of the literature of the efficacy of this treatment as well as the associated risks and complications.

Methods: A systematic review of the literature was performed using the PubMed, Google Scholar, and Scopus online electronic databases to identify articles reporting stem cell injections for axial back pain in accordance with the PRISMA guidelines. The primary focus was on outcomes and complications. A case of glial hyperplasia of the roots of the cauda equina directly related to stem cell injections performed abroad is also reported.

Results: The authors identified 14 publications (including a total of 147 patients) that met the search criteria. Three of the articles presented data for the same patient population with different durations of follow-up and were thus analyzed as a single study, reducing the total number of studies to 12. In these 12 studies, follow-up periods ranged from 6 months to 6 years, with 50% having a follow-up period of 1 year or less. Most studies reported favorable outcomes, although 36% used subjective measures. There was a tendency for pain relief to wane after 6 months to 2 years, with patients seeking a surgical solution. Only 1 study was a randomized controlled trial (RCT).

Conclusions: There are still insufficient data to support stem cell injections for back pain. Additional RCTs with long-term follow-up are necessary before statements can be made regarding the efficacy and safety.
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http://dx.doi.org/10.3171/2019.6.SPINE19594DOI Listing
September 2019

Traumatic Lumbar Interdural Cyst with Intradural Expansion and Compression of the Cauda Equina: Case Report and Surgical Video.

Cureus 2019 Jun 4;11(6):e4824. Epub 2019 Jun 4.

Neurosurgery, University of Texas Southwestern Medical Center, Dallas, USA.

Intradural arachnoid cysts are common entities that can be congenital, or caused by infectious, inflammatory, or even traumatic processes. However, true "inter"-dural cysts formed between the two lamellae of the lumbar dura without any fistulous arachnoid connection are rare. We present the case of a post-traumatic interdural cyst formation of the lumbar spine that compressed the roots of the cauda equina causing acute unrelenting pain. The cyst walls were formed by the true dural layers, and the cavity was filled with blood degradation products without any arachnoid connection to the subdural space. A commented video that details the diagnostic and surgical aspects of this case, alongside intraoperative footage is provided.
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http://dx.doi.org/10.7759/cureus.4824DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684201PMC
June 2019

Biplane Fluoroscopic-Guided Balloon Rhizotomy for Trigeminal Neuralgia: A Technical Note.

Oper Neurosurg (Hagerstown) 2020 03;18(3):295-301

Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas.

Background: The classic percutaneous technique used to cannulate the foramen ovale for the treatment of trigeminal neuralgia can place important anatomic structures, such as the distal cervical internal carotid artery, at risk.

Objective: To use fixed anatomic landmarks to safely and reliably locate the foramen ovale on anteroposterior (AP) fluoroscopy.

Methods: Locating the foramen ovale was initially tested using AP fluoroscopy on cadaveric skulls in the neurosurgical simulation lab. Fluoroscopic landmarks were identified and utilized to assist in successfully locating the foramen ovale during percutaneous balloon rhizotomy procedures in patients with trigeminal neuralgia. This technique has been successfully used in multiple patients. In this report, we describe our technique in detail.

Results: The AP fluoroscopy is directed laterally in the coronal plane until a line drawn inferiorly from the lateral orbital rim bisects the inner concavity of the mandibular angle. Fluoroscopy is then directed inferiorly until the top of the petrous ridge bisects the mandibular ramus. The foramen ovale will come into view within the window between the mandibular ramus and hard palate. Two case illustrations are provided.

Conclusion: Balloon rhizotomy is a commonly used treatment option for trigeminal neuralgia. Direct visualization of the foramen ovale can reliably be achieved on AP fluoroscopy using specific anatomic landmarks. This technique can be utilized to increase the accuracy and safety of the procedure.
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http://dx.doi.org/10.1093/ons/opz132DOI Listing
March 2020

Oculomotor Schwannomas: A Systematic Review and Report of Two Pediatric Cases Treated with Fractionated Cyberknife Stereotactic Radiotherapy.

World Neurosurg 2019 Sep 21;129:487-496. Epub 2019 May 21.

Department of Neurological Surgery, University of Texas Southwestern, Dallas, Texas, USA; Department of Radiation Oncology, University of Texas Southwestern, Dallas, Texas, USA.

Objective: Pediatric oculomotor nerve schwannomas are rare and challenging lesions due to the high morbidity associated with surgical intervention and their proximity to critical structures limiting the opportunity for stereotactic radiosurgery. We aim to report and review the novel use of fractionated Cyberknife (Accuray, Inc., Sunnyvale, California, USA) stereotactic radiotherapy in pediatric patients with oculomotor schwannomas.

Methods: A systematic review of PubMed, Embase, and Cochrane was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two patients, ages 8 and 10 years, with tumor volumes of 0.1 cm and 0.2 cm, respectively, were treated with fractionated Cyberknife radiotherapy at our institution. A total dose of 45-50 Gy was administered over 25 fractions (1.8-2.0 Gy per fraction) to the 82%-84% isodose line. Serial magnetic resonance imaging was obtained for long-term follow-up (56-58 months).

Results: We found 14 articles published between 1982 and 2018 that reported a total of 18 pediatric patients with intracranial oculomotor schwannomas. No previously described cases of pediatric intracranial oculomotor schwannomas were treated with radiation therapy. In both of our patients, radiographic tumor control was achieved at a mean follow-up of 57 months, with 1 patient displaying a decrease in tumor volume. Neither patient exhibited any worsening of their presenting symptoms, nor did either patient develop any new neurocognitive deficits following treatment.

Conclusions: Fractionated Cyberknife radiotherapy is an effective and well-tolerated treatment option for intracranial oculomotor nerve schwannomas with excellent tumor control rates, similar to surgical and radiosurgical techniques, while sparing critical surrounding structures.
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http://dx.doi.org/10.1016/j.wneu.2019.05.114DOI Listing
September 2019