Tag: Outcomes

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High Subarachnoid Hemorrhage Patient Volume Associated With Lower Mortality and Better Outcomes

Cerebral arterial fenestrations- a common phenomenon in unexplained subarachnoid haemorrhage

Neurosurgery 77:462–470, 2015

High-volume centers have better outcomes than low-volume centers when managing complex conditions including subarachnoid hemorrhage (SAH).

OBJECTIVE: To quantify SAH volume-outcome association and determine the extent to which this association is influenced by aggressiveness of care.

METHODS: A serial cross-sectional retrospective study using the Nationwide Inpatient Sample for 2002 to 2010 was performed. Included were all adult (older than 18 years of age) discharged patients with a primary diagnosis of SAH admitted from the emergency department or transferred to a discharging hospital; cases of trauma or arteriovenous malformation were excluded. Survey-weighted descriptive statistics estimated temporal trends. Multilevel logistic regression estimated volume-outcome associations for inpatient mortality and discharge home. Models were adjusted for demographic characteristics, year, transfer status, insurance status, all individual Charlson comorbidities, intubation, and all patient-refined, diagnosis-related group mortality. Analyses were repeated, excluding cases in which aggressive care was not pursued.

RESULTS: A total of 32336 discharges were included; 13398 patients underwent clipping (59.1%) or coiling (40.9%). The inpatient mortality rate decreased from 32.2% in 2002 to 22.2% in 2010; discharge home increased from 28.5% to 40.8% during the same period. As SAH volume decreased from 100/year, the mortality rate increased from 18.7% to 19.8% at 80/year, 21.7% at 60/year, 24.5% at 40/year, and 28.4% at 20/ year. As SAH patient volume decreased, the probability of discharge home decreased from 40.3% at 100/year to 38.7% at 60/year, and 35.3% at 20/year. Better outcomes persisted in patients receiving aggressive care and in those not receiving aggressive care.

CONCLUSION: Short-term SAH outcomes have improved. High-volume hospitals have more favorable outcomes than low-volume hospitals. This effect is substantial, even for hospitals conventionally classified as high volume.

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Management and outcomes of pituitary apoplexy

pituitary apoplexy

J Neurosurg 122:1450–1457, 2015

This study was undertaken to analyze the predisposing factors, clinical presentation, therapeutic management, and clinical recovery in patients with pituitary apoplexy, with an emphasis on the long-term visual, endocrine, and functional outcomes.

Methods The authors performed a retrospective analysis of consecutive cases involving patients treated at Mayo Clinic between 1992 and 2013. Patients were included in the study only if they had 1) abrupt onset of severe headache or visual disturbance in the presence of a pituitary adenoma and 2) radiological or surgical confirmation of a pituitary mass. The primary endpoints of analysis were the visual (ocular motility, visual fields, and visual acuity), endocrine, and functional outcomes (using the modified Rankin Scale).

Results Eighty-seven patients were identified (57 males and 30 females, mean age 50.9 years, range 15–91 years). Twenty-two patients (25.3%) had a known pituitary adenoma. Hypertension was the most common associated factor (39%). Headache was the most frequent presenting symptom (89.7%), followed by visual abnormalities (47.1%). Cranial nerve palsies were present in 39% and visual field defects in 34.1%. MRI detected hemorrhage in 89% patients, as compared with 42% detected by CT scan. Sixty-one patients (70.1%) underwent surgery during acute hospitalization (median time from apoplexy 5 days, IQR 3–10 days), 8 (9.2%) had delayed surgery, and 18 (20.7%) were treated conservatively. Histopathological examination revealed adenoma with pure necrosis in 18 (30%), pure hemorrhage in 4 (6.7%), and both in 6 (10%) patients. Four patients died during hospitalization. The average duration of follow-up was 44.2 ± 43.8 months. All survivors were independent and had complete resolution or substantial improvement in eye movements and visual fields at the last follow-up. Many patients needed long-term hormonal replacement with levothyroxine (62.7%) and cortisol (60%). Daily desmopressin was needed in 23% of all surgical patients at 3 months (versus none of the medically treated) and this requirement decreased slightly over time. Regrowth of pituitary adenoma was seen in 7 patients (8.6%). There were no statistically significant differences in any of the outcome measures across the treatment groups.

Conclusions The outcome of most patients with pituitary apoplexy is excellent. Selected patients can be managed conservatively, and patients with severe neuro-ophthalmological deficits treated with early surgery can achieve an excellent recovery.

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Clinical factors associated with venous thromboembolism risk in patients undergoing craniotomy

Awake craniotomy for gliomas in a high-field intraoperative magnetic resonance imaging suite

J Neurosurg 122:1004–1011, 2015

Patients undergoing craniotomy are at risk for developing venous thromboembolism (VTE). The safety of anticoagulation in these patients is not clear. The authors sought to identify risk factors predictive of VTE in patients undergoing craniotomy.

METHODS The authors reviewed a national surgical quality database, the American College of Surgeons National Surgical Quality Improvement Program. Craniotomy patients were identified by current procedural terminology code. Clinical factors were analyzed to identify associations with VTE.

RESULTS Four thousand eight hundred forty-four adult patients who underwent craniotomy were identified. The rate of VTE in the cohort was 3.5%, including pulmonary embolism in 1.4% and deep venous thrombosis in 2.6%. A number of factors were found to be statistically significant in multivariate binary logistic regression analysis, including craniotomy for tumor, transfer from acute care hospital, age ≥ 60 years, dependent functional status, tumor involving the CNS, sepsis, emergency surgery, surgery time ≥ 4 hours, postoperative urinary tract infection, postoperative pneumonia, on ventilator ≥ 48 hours postoperatively, and return to the operating room. Patients were assigned a score based on how many of these factors they had (minimum score 0, maximum score 12). Increasing score was predictive of increased VTE incidence, as well as risk of mortality, and time from surgery to discharge.

CONCLUSIONS Patients undergoing craniotomy are at low risk of developing VTE, but this risk is increased by preoperative medical comorbidities and postoperative complications. The presence of more of these clinical factors is associated with progressively increased VTE risk; patients possessing a VTE Risk Score of ≥ 5 had a greater than 20-fold increased risk of VTE compared with patients with a VTE score of 0.

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Cervical Spondylotic Myelopathy Surgical Trial: Randomized, Controlled Trial Design and Rationale

Cervical Spondylotic Myelopathy Surgical Trial- Randomized, Controlled Trial Design and Rationale

Neurosurgery 75:334–346, 2014

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in the world. There are significant practice variation and uncertainty as to the optimal surgical approach for treating CSM.

OBJECTIVE: To determine whether ventral surgery is associated with superior Short Form- 36 Physical Component Summary outcome at the 1-year follow-up compared with dorsal (laminectomy/fusion or laminoplasty) surgery for the treatment of CSM, to investigate whether postoperative sagittal balance is an independent predictor of overall outcome, and to compare health resource use for ventral and dorsal procedures.

METHODS: The study is a randomized, controlled trial with a nonrandomized arm for patients who are eligible but decline randomization. Two hundred fifty patients (159 randomized) with CSM from 11 sites will be recruited over 18 months. The primary outcome is the Short Form-36 Physical Component Summary score. Secondary outcomes include disease-specific outcomes, overall health-related quality of life (EuroQOL 5-dimension questionnaire), and health resource use.

EXPECTED OUTCOMES: This will be the first randomized, controlled trial to compare directly the health-related quality-of-life outcomes for ventral vs dorsal surgery for treating CSM.

DISCUSSION: A National Institutes of Health-funded (1R13AR065834-01) investigator meeting was held before the initiation of the trial to bring multiple stakeholders together to finalize the study protocol. Study investigators, coordinators, and major stakeholders were able to attend and discuss strengths of, limitations of, and concerns about the study. The final protocol was approved for funding by the Patient-Centered Outcomes Research Institute (CE-1304-6173). The trial began enrollment on April 1, 2014.

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Minimally invasive spine surgery for adult degenerative lumbar scoliosis

Minimally invasive spine surgery for adult degenerative lumbar scoliosis

Neurosurg Focus 36 (5):E7, 2014

Historically, adult degenerative lumbar scoliosis (DLS) has been treated with multilevel decompression and instrumented fusion to reduce neural compression and stabilize the spinal column. However, due to the profound morbidity associated with complex multilevel surgery, particularly in elderly patients and those with multiple medical comorbidities, minimally invasive surgical approaches have been proposed. The goal of this meta-analysis was to review the differences in patient selection for minimally invasive surgical versus open surgical procedures for adult DLS, and to compare the postoperative outcomes following minimally invasive surgery (MIS) and open surgery.

Methods. In this meta-analysis the authors analyzed the complication rates and the clinical outcomes for patients with adult DLS undergoing complex decompressive procedures with fusion versus minimally invasive surgical approaches. Minimally invasive surgical approaches included decompressive laminectomy, microscopic decompression, lateral and extreme lateral interbody fusion (XLIF), and percutaneous pedicle screw placement for fusion. Mean patient age, complication rates, reoperation rates, Cobb angle, and measures of sagittal balance were investigated and compared between groups.

Results. Twelve studies were identified for comparison in the MIS group, with 8 studies describing the lateral interbody fusion or XLIF and 4 studies describing decompression without fusion. In the decompression MIS group, the mean preoperative Cobb angle was 16.7° and mean postoperative Cobb angle was 18°. In the XLIF group, mean pre- and postoperative Cobb angles were 22.3° and 9.2°, respectively. The difference in postoperative Cobb angle was statistically significant between groups on 1-way ANOVA (p = 0.014). Mean preoperative Cobb angle, mean patient age, and complication rate did not differ between the XLIF and decompression groups. Thirty-five studies were identified for inclusion in the open surgery group, with 18 studies describing patients with open fusion without osteotomy and 17 papers detailing outcomes after open fusion with osteotomy. Mean preoperative curve in the open fusion without osteotomy and with osteotomy groups was 41.3° and 32°, respectively. Mean reoperation rate was significantly higher in the osteotomy group (p = 0.008). On 1-way ANOVA comparing all groups, there was a statistically significant difference in mean age (p = 0.004) and mean preoperative curve (p = 0.002). There was no statistically significant difference in complication rates between groups (p = 0.28).

Conclusions. The results of this study suggest that surgeons are offering patients open surgery or MIS depending on their age and the severity of their deformity. Greater sagittal and coronal correction was noted in the XLIF versus decompression only MIS groups. Larger Cobb angles, greater sagittal imbalance, and higher reoperation rates were found in studies reporting the use of open fusion with osteotomy. Although complication rates did not significantly differ between groups, these data are difficult to interpret given the heterogeneity in reporting complications between studies.

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Fifty Consecutive Hemispherectomies

50 Hemispherectomies

Neurosurgery 74:182–195, 2014

Techniques for achieving hemispheric disconnection in patients with epilepsy continue to evolve.

OBJECTIVE: To review the outcomes of the first 50 hemispherectomy surgeries performed by a single surgeon with an emphasis on outcomes, complications, and how these results led to changes in practice.

METHODS: The first 50 hemispherectomy cases performed by the lead author were identified from a prospectively maintained database. Patient demographics, surgical details, clinical outcomes, and complications were critically reviewed.

RESULTS: From 2004 to 2012, 50 patients underwent hemispherectomy surgery (mean follow-up time, 3.5 years). Modified lateral hemispherotomy became the preferred technique and was performed on 44 patients. Forty patients (80%) achieved complete seizure freedom (Engel I). Presurgical and postsurgical neuropsychological evaluations demonstrated cognitive stability. Two cases were performed for palliation only. Previous hemispherectomy surgery was associated with worsened seizure outcome (2 of 6 seizure free; P .005). The use of Avitene was associated with a higher incidence of postoperative hydrocephalus (56% vs 18%; P = .03). In modified lateral hemispherotomy patients without the use of Avitene, the incidence of hydrocephalus was 13%. Complications included infection (n = 3), incomplete disconnection requiring reoperation (n = 1), reversible ischemic neurological deficit (n = 1), and craniosynostosis (n = 1). There were no (unanticipated) permanent neurological deficits or deaths. Minor technique modifications were made in response to specific complications.

CONCLUSION: The modified lateral hemispherotomy is effective and safe for both initial and revision hemispherectomy surgery. Avitene use appears to result in a greater incidence of postoperative hydrocephalus.

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Reoperation for Refractory Epilepsy in Childhood: A Second Chance for Selected Patients

FCD

Neurosurgery 73:695–704, 2013

Reoperations account for 10% in pediatric epilepsy surgery cohorts, and they are especially relevant in young children with catastrophic epilepsy. OBJECTIVE: To determine surgical outcomes and their predictive factors in reoperations for refractory epilepsy in childhood.

METHODS: We retrospectively analyzed presurgical findings, resections, and outcomes of 23 consecutive children who underwent reoperations from 2000 to 2011.

RESULTS: Etiology included cortical dysplasia with/without glioneuronal tumor in 19 patients (83%), sole glioneuronal tumor in 2, and tuberous sclerosis and Rasmussen encephalitis in 1 each. The reasons for the failure of the initial surgery were functional considerations in 8 (35%), incorrect delineation of the epileptogenic zone in 8 (35%), and resection not performed as initially planned in 7 (30%) cases. Final procedures included 8 (35%) intralobar, 8 (35%) multilobar resections, and 7 (30%) hemispherotomies. Following reoperations, 14 (61%) patients were seizure free, 6 (26%) showed significant or worthwhile improvement, and 3 (13%) did not respond to surgery. Six of 8 patients who underwent the first resection before the age of 3 years, 6 of 8 whose first resection was limited by functional considerations, and all 7 with hemispherotomy as the final resection achieved seizure freedom after reoperation.

CONCLUSION: Reoperation is particularly beneficial for selected children with refractory epilepsy associated with cortical dysplasia that did not respond to an initial limited and/or early resection but achieved seizure freedom after extensive procedures. When indicated, reoperation should be performed at the youngest possible age to profit from higher functional plasticity in compensating for neurological deficit.

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Biopsy of the Superficial Cortex: Predictors of Effectiveness and Outcomes

Biopsy of the Superficial Cortex

Neurosurgery 73:224–232, 2013 

Brain biopsies of superficial cortex are performed for diagnosis of neurological diseases, but preoperative predictors of successful diagnosis and risks are lacking.

OBJECTIVE: We evaluated effectiveness and outcomes of superficial cortical biopsies and determined preoperative predictors of diagnosis, outcomes, morbidities, and mortality.

METHODS: A single-institution retrospective analysis of 170 patients who underwent open brain biopsies of superficial cortex was performed. Clinical predictors of effectiveness and outcomes were determined using univariate/multivariate analyses and a system for risk-benefit stratification was created and tested.

RESULTS: Brain biopsies led to successful diagnosis in 122 of 170 (71.8%) and affected management in 97 of 170 (57.1%) cases. Factors increasing the odds of diagnostic pathology included age older than 45 years (odds ratio [OR]: 2.67, 95% confidence interval [CI]: 1.34-5.27, P < .01), previous cancer diagnosis (OR: 3.64, 95% CI: 1.69-7.85, P < .001), focal (OR: 3.90, 95% CI: 1.91-8.00, P< .001) and enhancing (OR: 5.03, 95% CI: 2.41-10.52, P< .001) lesions on magnetic resonance imaging, biopsy of specific lesions on magnetic resonance imaging (OR: 9.34, 95% CI: 4.29-20.33, P < .001), and use of intraoperative navigation (OR: 6.59, 95% CI: 3.04-14.28, P < .001). Brain biopsies led to symptomatic intracranial hemorrhage, seizures, other significant morbidities, and perioperative mortality in 12.4%, 16.2%, 37.1%, and 8% of cases, respectively. Risk of postoperative intracranial hemorrhage was increased by a history of aspirin use (OR: 2.51, 95% CI: 1.23-5.28, P < .05) and age older than 60 years (OR: 2.66, 95% CI: 1.36-5.18, P < .01).

CONCLUSION: Effectiveness and risk of morbidity/mortality can be estimated preoperatively for patients undergoing open brain biopsies of the superficial cortex. Older age and specific imaging characteristics increase the odds of diagnostic biopsy. Conversely, older age and aspirin use increases the risk of postoperative complications.

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Diastematomyelia: A 35-Year Experience

Dyastematomyelia

SPINE Volume 38, Number 6, pp E344–E349

Diastematomyelia is a rare entity, which presents distinct clinical characteristics and requires different managements compared with other more common occult spinal dysraphism.

Methods. A total of 156 patients with diastematomyelia were reviewed. All the patients underwent neurological and radiological examinations. Surgical excision of the lesion was performed for most patients and intradural exploration of the lumbar region was done to release tethering of conus in some patients. One patient died and autopsy was performed. Follow-up was carried out for all the patients, including surgical and nonsurgical approaches.

Results. There were 123 cases of type I diastematomyelia and 33 cases of type II diastematomyelia. The lumbar and thoracolumbar region was the most common site for diastematomyelia, and most spinal cords were split among 6 segments. The postoperative course was complicated by cerebrospinal fl uid leakage in 2 patients, temporary neurological deterioration in 4 patients, and epidural hematoma in 1 patient. All cases did not have aggravation of symptoms during the follow-up of 2 to 20 years (mean of 4.5 yr). For the 123 patients with type I diastematomyelia, clinical symptoms were improved in 96 after surgical intervention and no worsening or occurrence of new clinical signs were observed during the follow-up. Those who did not receive surgery showed stabilization of neurological manifestation. Of the 33 type II cases, 9 surgical patients remained neurologically stable during the postoperative years without signifi cant improvement in function, and 24 nonsurgical patients neither improved nor worsened in their neural defi cit.

Conclusion. Surgical treatment is the necessary management for type I diastematomyelia causing progressive neurological deterioration or with tethered fi lum, whereas conservative treatment is recommended to asymptomatic type I diastematomyelia and all type II diastematomyelia.

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Spine Patient Outcomes Research Trial: Do Outcomes Vary Across Centers for Surgery for Lumbar Disc Herniation?

Neurosurgery 71:833–843, 2012

Lumbar discectomy is the most commonly performed spine procedure. Academic spine centers with potentially differing caseloads and experience may have different outcomes.

OBJECTIVE: To determine whether the choice of center in which surgery is performed affects lumbar discectomy outcomes.

METHODS: Spine Patient Outcomes Research Trial participants with a confirmed diagnosis of intervertebral disc herniation undergoing standard first-time open discectomy were followed from baseline at 6 weeks, and 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Patient data from this prospective study were reviewed. Enrollment began in March 2000 and ended in November 2004.

RESULTS: Seven hundred ninety-two patients underwent first-time lumbar discectomy. Significant differences were found among centers in patient age and race, baseline levels of disability, and treatment preferences. There were no significant differences among the centers in other patient characteristics (eg, sex, body mass index, the prevalence of smoking, diabetes, or hypertension), or disease characteristics (herniation level or type). Some short-term outcomes varied significantly among centers, including operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and reoperation rate. However, there were no differences among the centers in incidence of nerve root injury, postoperative mortality, Short Form 36 scores of body pain or physical function, or Oswestry Disability Index at 4 years.

CONCLUSION: Although mean blood loss, risk of durotomy, length of stay, and rate of reoperation vary among academic spine centers performing lumbar discectomy, there appears to be no difference in long-term functional outcomes.

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Morbidity and Mortality of C2 Fractures in the Elderly- Surgery and Conservative Treatment

Neurosurgery 70:1055–1059, 2012 DOI: 10.1227/NEU.0b013e3182446742

Closed C2 fractures commonly occur after falls or other trauma in the elderly and are associated with significant morbidity and mortality. Controversy exists as to best treatment practices for these patients.

OBJECTIVE: To compare outcomes for elderly patients with closed C2 fractures by treatment modality.

METHODS: We retrospectively reviewed 28 surgically and 28 nonsurgically treated cases of closed C2 fractures without spinal cord injury in patients aged 65 years of age or older treated at Stanford Hospital between January 2000 and July 2010. Comorbidities, fracture characteristics, and treatment details were recorded; primary outcomes were 30-day mortality and complication rates; secondary outcomes were length of hospital stay and long-term survival.

RESULTS: Surgically treated patients tended to have more severe fractures with larger displacement. Charlson comorbidity scores were similar in both groups. Thirty-day mortality was 3.6% in the surgical group and 7.1% in the nonsurgical group, and the 30-day complication rates were 17.9% and 25.0%, respectively; these differences were not statistically significant. Surgical patients had significantly longer lengths of hospital stay than nonsurgical patients (11.8 days vs 4.4 days). Long-term median survival was not significantly different between groups.

CONCLUSION: The 30-day mortality and complication rates in surgically and nonsurgically treated patients were comparable. Elderly patients faced relatively high morbidity and mortality regardless of treatment modality; thus, age alone does not appear to be a contraindication to surgical fixation of C2 fractures.

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SPORT: Does Incidental Durotomy Affect Longterm Outcomes in Cases of Spinal Stenosis?

Neurosurgery 69:38–44, 2011 DOI: 10.1227/NEU.0b013e3182134171

Incidental durotomy is a familiar encounter during surgery for lumbar spinal stenosis. The impact of durotomy on long-term outcomes remains a matter of debate.

OBJECTIVE: To determine the impact of durotomy on the long-term outcomes of patients in the Spine Patient Outcomes Research Trial (SPORT).

METHODS: The SPORT cohort participants with a confirmed diagnosis of spinal stenosis, without associated spondylolisthesis, undergoing standard, first-time, open decompressive laminectomy, with or without fusion, were followed up from baseline at 6 weeks, and 3, 6, and 12 months and yearly thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean follow-up among all analyzed patients was 43.8 months.

RESULTS: Four hundred nine patients underwent first-time open laminectomy with or without fusion. Thirty-seven of these patients (9%) had an incidental durotomy. No significant differences were observed with or without durotomy in age; sex; race; body mass index; the prevalence of smoking, diabetes mellitus, and hypertension; decompression level; number of levels decompressed; or whether an additional fusion was performed. The durotomy group had significantly increased operative duration, operative blood loss, and inpatient stay. There were, however, no differences in incidence of nerve root injury, mortality, additional surgeries, or primary outcomes (Short Form-36 Bodily Pain or Physical Function scores or Oswestry Disability Index) at yearly follow-ups to 4 years.

CONCLUSIONS: Incidental durotomy during first-time lumbar laminectomy for spinal stenosis did not impact long-term outcomes in affected patients.

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Intraoperative and Early Postoperative Complications in Extreme Lateral Interbody Fusion. An Analysis of 600 Cases

SPINE Volume 36, Number 1, pp 26–33

Study Design. Prospective analysis of 600 extreme lateral interbody fusion (XLIF) approach procedures for intraoperative and perioperative complications.

Objective. To delineate and describe complications in a large, prospective series of minimally invasive lateral lumbar fusion procedures (XLIF).

Summary of Background Data. While some small series of lateral lumbar fusion have discussed complications, no results from large studies have been reported.

Methods. A total of 600 patients were treated with a lateral approach to fusion (XLIF) for degenerative spinal conditions. Data were collected prospectively on all patients and analyzed for demographic, diagnostic, and hospitalization information to identify operative and early postoperative complications. Documented complication types and rates in this large series were compared with smaller prior reports on lateral approach fusions, as well as other minimally invasive (mini-anterior lumbar interbody fusion and minimally invasive surgical [MIS] transforaminal lumbar interbody fusion) and more traditional fusion approaches (posterior intertransverse fusion, anterior lumbar interbody fusion, posterior lumbar interbody fusion, transforaminal lumbar interbody fusion).

Results. Seven hundred forty-one levels were treated, 80.8% single level, 15.0% 2 level, 4.0% 3 level, 0.2% 4 level; 59.3%, including the L4 to L5 levels. A total of 99.2% included supplemental internal fi xation; 83.2% included pedicle screw fi xation (predominantly unilateral). Hemoglobin change from pre- to postoperation averaged 1.38. Hospital stay averaged 1.21 days. The overall incidence of perioperative complications (intraoperation and out to 6 weeks postoperation) was 6.2%: 9 (1.5%) in-hospital surgery-related events, 17 (2.8%) in-hospital medical events, 6 (1.0%) out-of-hospital surgery-related events, and 5 (0.8%) out-of-hospital medical events. There were no wound infections, no vascular injuries, no intraoperative visceral injuries, and 4 (0.7%) transient postoperative neurologic defi cits. Eleven events (1.8%) resulted in additional procedures/reoperation.

Conclusions. Compared with traditional open approaches, the MIS lateral approach to fusion by using the XLIF technique resulted in a lower incidence of infection, visceral and neurologic injury, and transfusion as well as markedly shorter hospitalization. Complications in MIS XLIF compare favorably with those from other MIS fusion procedures; duration of hospitalization is shorter than with any previously reported technique.

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Clinical Characteristics and Surgical Outcomes of Patients Presenting With Meningiomas Arising Predominantly From the Floor of the Middle Fossa

Neurosurgery 67:80-86, 2010. DOI: 10.1227/01.NEU.0000370938.46353.77

Little is known regarding meningiomas that primarily arise from the floor of the middle fossa as opposed to the sphenoid wing, the cavernous sinus, the anterior petrous ridge, or the lateral convexity dura.

OBJECTIVE: Given the relative paucity of literature addressing this disease entity, we review the University of California at San Francisco (UCSF) experience with these tumors.

METHODS: Between 1991 and 2006, 1228 patients were seen by neurosurgeons at UCSF for meningiomas of which 17 (1.1%) patients met our criteria for a “middle fossa floor” meningioma, of which 15 underwent first-time surgery and were included in this series. The most common presenting symptoms were headache (9 patients), seizures (6 patients), trigeminal nerve dysfunction (5 patients), hearing loss (5 patients), gait disturbance (5 patients), and cognitive decline (3 patients). All patients underwent surgical resection via frontotemporal craniotomy, with or without orbitozygomatic osteotomy.

RESULTS:We were able to achieve a Simpson grade 1 or 2 resection in 10 of 15 patients (67%). The operative morbidity was clustered in 5 patients, as 10 of 15 patients (67%) experienced no operative morbidity. There were 4 known clinical recurrences in this group at 5 years median follow-up. All patients had either higher grade tumors, or received a Simpson grade 3 or higher resection.

CONCLUSION:We present the clinical characteristics and surgical outcome of a series of patients presenting with meningiomas primarily arising from the concave floor of the middle cranial fossa. Given the relatively uncommon nature of these lesions, more investigation into the clinical behavior of this entity is warranted.

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Surgical treatment of the extratemporal epilepsies

Epilepsia, Aug 12 2009

Epilepsy that originates outside of the temporal lobe can present some of the most challenging problems for surgical therapy. These epilepsies can be broadly categorized as lesional or non-lesional, with the nonlesional cases being the most difficult to localize. Lesional cases can result from malformations of cortical development, tumors, vascular malformations, or areas of old injury. Some lesions, such as focal cortical dysplasia, can be challenging, in that the boundaries of the pathology can be difficult to define. Presurgical goals include defining the structural lesion, the physiologic abnormality, and normal function in the area. These goals can be achieved using a variety of noninvasive and invasive tests. Surgical techniques vary depending on location and pathology but they always include removal of the epileptic brain tissue while preserving en passage vessels and underlying white matter tracts. Surgical outcomes vary depending on the underlying pathology. Surgeries are usually planned with a goal of no expected postoperative deficits, although temporary deficits may be anticipated in some areas, such as the supplementary motor cortex. Extratemporal epilepsy can be managed well with surgical treatment; but proper patient selection, evaluation, and discussion of expected outcomes and risks are critical in this challenging patient population.

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