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Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

Surgical management and long-term outcome of intracranial subependymoma

Acta Neurochirurgica (2018) 160:1793–1799

Intracranial subependymomas account for 0.2–0.7% of central nervous system tumours and are classified as World Health Organization (WHO) grade 1 tumours. They are typically located within the ventricular system and are detected incidentally or with symptoms of hydrocephalus. Due to paucity of studies exploring this tumour type, the objective was to determine the medium- to long-term outcome of intracranial subependymoma treated by surgical resection.

Methods Retrospective case note review of adults with intracranial WHO grade 1 subependymoma diagnosed between 1990 and 2015 at the Walton Centre NHS Foundation Trust was undertaken. Tumour location, extent of resection (defined as gross total resection (GTR), sub-total resection (STR) or biopsy) and the WHO performance status at presentation and through follow-up were recorded.

Results Thirteen patients (7 males; 6 females) with a mean age of 47.6 years (range 33–58 years) and a median follow-up of 46 months (range 25–220 months) were studied. Eight patients had symptomatic tumours (headache, visual disturbance); five had incidental finding. Tumours were most commonly located in the fourth ventricle (n = 8). The performance status scores at diagnosis were 0 (n = 8) and 1 (n = 5). The early post-operative performance status scores at 6 months were 0 (n = 5) and 1 (n = 8) and at last follow-up were 0 (n = 11) and 1 (n = 2). There was no evidence of tumour re-growth following GTR or STR. The commonest complication was hydrocephalus (n = 3).

Conclusion Subependymoma are indolent tumours. No patients exhibited a worsening of performance status at medium- to longterm follow-up and there were no tumour recurrence suggesting a shorter follow-up time may be sufficient. Surgical resection is indicated for symptomatic tumours or those without a clear imaging diagnosis. Incidental intraventricular subependymoma can be managed conservatively through MRI surveillance.

Volumetric growth rates of meningioma and its correlation with histological diagnosis and clinical outcome

Acta Neurochir (2017) 159:435–445

Tumour growth has been used to successfully predict progression-free survival in low-grade glioma. This systematic review sought to establish the evidence base regarding the correlation of volumetric growth rates with histological diagnosis and potential to predict clinical outcome in patients with meningioma.

Methods This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Databases were searched for full text English articles analysing volumetric growth rates in patients with a meningioma.

Results Four retrospective cohort studies were accepted, demonstrating limited evidence of significantly different tumour doubling rates and shapes of growth curves between benign and atypical meningiomas. Heterogeneity of patient characteristics and timing of volumetric assessment, both pre- and post-operatively, limited pooled analysis of the data. No studies performed statistical analysis to demonstrate the clinical utility of growth rates in predicting clinical outcome.

Conclusion This systematic review provides limited evidence in support of the use of volumetric growth rates in meningioma to predict histological diagnosis and clinical outcome to guide future monitoring and treatment.

Syndrome of the Trephined: A Systematic Review

syndrome-of-the-trephined-a-systematic-review

Neurosurgery 79:525–534, 2016

Syndrome of the trephined (SoT) is a rare, important complication of a craniectomy characterized by neurological dysfunction that improves with cranioplasty. Its varied symptoms include motor, cognitive, and language deficits. Its exact characterization appears suboptimal, with differing approaches of evaluation. Accordingly, this topic is in great need of further investigation.

OBJECTIVE: To accurately describe SoT and explore methods of an objective diagnosis/ evaluation.

METHODS: Electronic searches of PubMed, MEDLINE, Web of Knowledge, and PsycINFO databases used the key words “syndrome of the trephined” and “sinking skin flap.” Non–English-language and duplicate articles were eliminated. Title and abstract reviews were selected for relevance. Full-text reviews were selected for articles providing individual characteristics of SoT patients.

RESULTS: This review identified that SoT most often occurs in male patients (60%) at 5.1 6 10.8 months after craniectomy for neurotrauma (38%). The average reported craniectomy is 88.3 6 34.4 cm2 and usually exists with a “sunken skin flap” (93%). Symptoms most commonly include motor, cognitive, and language deficits (57%, 41%, 28%, respectively), with improvement after cranioplasty within 3.8 6 3.9 days. Functional independence with activities of daily living is achieved by 54.9% of patients after 2.9 6 3.4 months of rehabilitation. However, evaluation of SoT is inconsistent, with only 53% of reports documenting objective studies.

DISCUSSION: SoT is a variable phenomenon associated with a prolonged time to cranioplasty. Due to current weaknesses in objectivity, we hypothesize that SoT is often underdiagnosed and recommend a multifaceted approach for consistent evaluation.

CONCLUSION: SoT is a serious complication that lacks exact characterization and deserves future investigation. Improved understanding and recognition have important implications for early intervention and patient outcomes.

The Recent Revolution in the Design and Manufacture of Cranial Implants

The Recent Revolution in the Design and Manufacture of Cranial Implants

Neurosurgery 77:814–824, 2015

Large format (ie, .>25 cm2) cranioplasty is a challenging procedure not only from a cosmesis standpoint, but also in terms of ensuring that the patient’s brain will be well-protected from direct trauma.

Until recently, when a patient’s own cranial flap was unavailable, these goals were unattainable. Recent advances in implant computer-aided design and 3-dimensional (3-D) printing are leveraging other advances in regenerative medicine. It is now possible to 3-D-print patient-specific implants from a variety of polymer, ceramic, or metal components.

A skull template may be used to design the external shape of an implant that will become well integrated in the skull, while also providing beneficial distribution of mechanical force in the event of trauma.

Furthermore, an internal pore geometry can be utilized to facilitate the seeding of banked allograft cells. Implants may be cultured in a bioreactor along with recombinant growth factors to produce implants coated with bone progenitor cells and extracellular matrix that appear to the body as a graft, albeit a tissue-engineered graft.

The growth factors would be left behind in the bioreactor and the graft would resorb as new host bone invades the space and is remodeled into strong bone. As we describe in this review, such advancements will lead to optimal replacement of cranial defects that are both patient-specific and regenerative.

Emergency Noninvasive Angiography for Acute Intracerebral Hemorrhage

CTA

Am J Neuroradiol 34:1481– 87. 2013

Spontaneous ICH is a devastating condition and is associated with significant mortality in the acute phase due to ongoing hemorrhage and hematoma expansion. A growing body of evidence suggests that there may be considerable utility in performing noninvasive vascular imaging during the acute-to-early phase of ICH.

CTA has become widely available and is sensitive and specific for detecting vascular causes of secondary ICH such as aneurysms, arteriovenous malformations, dural arteriovenous fistulas, intracranial dissections, and neoplasm.

CT venography can also diagnose dural sinus thrombosis presenting as hemorrhagic infarction.

Recent data from stroke populations demonstrate a relatively low risk to patients when contrast is administered in the absence of a known serum creatinine. Detection of acute contrast extravasation within the hematoma (“spot sign”) with CT angiography is predictive of subsequent hematoma expansion and is associated with increased morbidity and mortality.

Risk stratification based on acute CTA can inform and expedite decision-making regarding intensive care unit admission, blood pressure control, correction of coagulopathy, and neurosurgical consultation. Noninvasive vascular imaging should be considered as an important component of the initial diagnostic work-up for patients presenting with acute ICH.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain

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