NO LINK BETWEEN INADVERTENT SURGICAL GLOVE CONTAMINATION AND SURGICAL SITE INFECTION IN PATIENTS UNDERGOING ELECTIVE NEUROSURGICAL OPERATIONS

INTRODUCTION

Controllable factors associated with surgical site infections have focused on reducing contamination of the surgical field with potential pathogens. The aim of this prospective study is to determine the incidence of glove contamination in a series of elective neurosurgical operations and determine the relationship of such glove contamination to subsequent SSI. We hypothesize that contamination of surgical gloves is associated with subsequent surgical site infection.

METHODS

In this prospective quality improvement study, gloves of the surgical team were swabbed for standard culture just prior to wound closure of elective neurosurgical operations. Patient characteristics, surgical details, and occurrence of subsequent surgical site infections were collected retrospectively from the electronic medical records. Data was analysis with Chi-square with Fisher's Exact test and Student's t test.

RESULTS

Surgical glove contamination occurred in 10 of 96 elective neurosurgical cases (10.4%). Surgical site infections occurred in 6 cases (6.2%), but no SSI occurred in a case in which surgical glove contamination occurred (p = 1). Surgical site infection was associated with younger patient age (p = 0.0448), and surgical glove contamination was associated with less resident experience (p = 0.0354).

CONCLUSION

Surgical glove contamination identified at the time of wound closure does not correlate with development of subsequent SSI in elective neurosurgical operations.

Diagnosis and Management of Pineal Germinoma: From Eye to Brain

Pineal germinomas can be very complex in terms of presentation, diagnosis, and management. This review attempts to simplify this complexity in an organized manner, addressing the anatomic relationships that provide the basis for the uniqueness of pineal germinoma. Ocular findings and signs and symptoms of elevated intracranial pressure are the keys to suspecting the diagnosis and obtaining the necessary imaging and cerebrospinal fluid studies. Other symptoms can suggest spread beyond the pineal region. Surgery may only be needed to obtain tissue for a definitive diagnosis, as germinoma is highly responsive to chemotherapy and focused radiation therapy. Hydrocephalus, usually related to tumor obstruction of the cerebral aqueduct, may also need to be addressed. Outcome for pineal germinoma is usually excellent, but relapse can occur and may require additional intervention. These issues are detailed in this review.

Linac-based hypofractionated stereotactic radiotherapy for metastases involving the brainstem

The long-term efficacy and complications of hypofractionated stereotactic radiotherapy (hSRT) to metastases involving the brainstem are not well reported. Our objective is to review the results of metastases intrinsic to or abutting the brainstem treatedwith hSRT.Patients treated with hSRT in 5 fractions at our institution from 2016 to 2020 were retrospectively reviewed. Varian Eclipse v13.7 TPS was used for treatment planning. MRI images were fused with CT images acquired at the time of simulation, and contoured structures include the brainstem, the GTV, and a 2 mm margin was used to generate the PTV. MR imaging was performed at 3-month intervals. Survival was assessed at the last available follow-up; tumor control was assessed at 6 and 12 months and toxicity was assessed based on the Radiation Therapy Oncology Group grading system at regular follow-up. Twenty patients were treated with 5 fraction treatment dose plans ranging from 20 Gy - 31.25 Gy. GTV mean volume was 3.5 cc ± 4.3 cc (range 0.1 cc - 18.9 cc). The median overall survival was 6.5 months (range: 1 to 29 months). The twelve-month tumor control rate was 80%. Toxicity was generally mild, with only one patient demonstrating Grade 3 toxicity. Two patients had radiographic progression, but neither required surgical intervention. In our series, hSRT resulted in similar rates of survival, tumor control, and toxicity as compared with published single fraction series. Dose escalation of lesions adjacent to the brainstem can be considered and maybe more feasible with a hypofractionated regimen of 5 fractions.

Squamous Cell Carcinoma of the Temporal Bone Arising from Cholesteatoma: A Case Report and Review of the Literature

Objective  Present a case of squamous cell carcinoma of the temporal bone (SCCTB) arising in a 61-year-old female with a prior history of cholesteatoma and persistent otologic symptoms and review the current literature regarding this disease presentation.

Setting  Tertiary academic center.

Patient  A 61-year-old female with a history of left ear cholesteatoma for which she had undergone surgery 54 years prior. The patient presented with a persistent history of otorrhea since first surgery and developed exacerbation of symptoms just prior to presentation at our department. The clinical picture was highly suspicious of cholesteatoma recurrence. However, the biopsy was consistent with squamous cell carcinoma.

Intervention  Surgical debulking of the lesion was followed by a brief course of radiation therapy later halted by the patient due to side effect intolerance.

Conclusion  SCCTB may arise from cholesteatoma. A high index of suspicion for SCCTB should be maintained in patients with a prior history of cholesteatoma and evidence of a temporal bone mass with persistent otologic symptoms.

Bifrontal Osteoplastic Flap: An Option to Decrease Infection in Bifrontal Craniotomies with Skull Base Osteotomies

Infection can be a common complication following bifrontal craniotomy with skull base osteotomies given the potential violation of sinuses and entry into the nasal structures. Our objective was to examine our series of patients who underwent a bifrontal craniotomy with skull base osteotomies and describe the infection rate. We propose the bifrontal osteoplastic flap as an adjunct to infection prevention. A retrospective single-center study of a patient database was performed. Twenty patients were identified. Fifty-five percent were male. The mean age was 55.7 ± 13.9 years. The most common indications for surgery were esthesioneuroblastomas (35%) and anterior skull base meningiomas (30%). Six patients (30%) developed an infection, 1 patient (5%) developed a CSF leak, and no patients developed a mucocele. All 6 infected cases had nasal pathology with intracranial extension, they all received chemoradiation post-operatively and were all combined cases with otorhinolaryngology. Eighty-three percent of these patients required a craniectomy and all of them required long-term IV antibiotics. Infection is not uncommon after a bifrontal craniotomy with skull base osteotomies and the use of the bifrontal osteoplastic flap in cases where the risk of infection is high, i.e., esthesioneuroblastomas surgery, may help reduce said risk and lead to better patient outcomes.

The impact of cigarette smoking and nicotine on traumatic brain injury: a review

INTRODUCTION

Traumatic Brain Injury (TBI) and tobacco smoking are both serious public health problems. Many people with TBI also smoke. Nicotine, a component of tobacco smoke, has been identified as a premorbid neuroprotectant in other neurological disorders. This study aims to provide better understanding of relationships between tobacco smoking and nicotine use and effect on outcome/recovery from TBI.

METHODS

PubMed database, SCOPUS, and PTSDpub were searched for relevant English-language papers.

RESULTS

Twenty-nine human clinical studies and nine animal studies were included. No nicotine-replacement product use in human TBI clinical studies were identified. While smoking tobacco prior to injury can be harmful primarily due to systemic effects that can compromise brain function, animal studies suggest that nicotine as a pharmacological agent may augment recovery of cognitive deficits caused by TBI.

CONCLUSIONS

While tobacco smoking before or after TBI has been associated with potential harms, many clinical studies downplay correlations for most expected domains. On the other hand, nicotine could provide potential treatment for cognitive deficits following TBI by reversing impaired signaling pathways in the brain including those involving nAChRs, TH, and dopamine. Future studies regarding the impact of cigarette smoking and vaping on patients with TBI are needed .

The impact of poor post-operative glucose control on neurosurgical surgical site infections (SSI)

Elevated HbA1c is associated with increased surgical site infections (SSI) in neurosurgical patients. How blood glucose control in the early post-operative period relates to SSI is incompletely understood. We hypothesized that poor early post-operative blood glucose control would be associated with SSI. Data from patients undergoing neurosurgical procedures at University of Missouri Hospital was retrospectively collected. Post-operative blood glucose for 72 h after surgery was assessed and categorized by levels of hyperglycemia; those with glucose ≥200 mg/dl were classified as poorly controlled. Patients with SSI were compared to patients without SSI using Chi-Square test with Fisher's exact test when appropriate. Of 500 patients having surgery, 300 had at least one post-operative blood glucose measurement. Of those 300 patients, 19 (6.33%) developed SSI. Patients with SSI had significantly higher mean post-operative blood glucose levels (p = 0.0081) and a greater mean number of point-of-care glucose level measurements >150 mg/dL (p = 0.0434). Pre-operative HbA1c and SSI were not associated (p = 0.0867). SSI was associated with pre-operative glucocorticoid use (p = 0.03), longer operative procedure (p = 0.0072), and required use of post-operative insulin drip (p = 0.047). Incidence of other wound complications (cellulitis, deep infection, dehiscence) increased with increase in post-operative blood glucose levels to >225 mg/dL. Post-operative hyperglycemia is associated with SSI after neurosurgical procedures, emphasizing the importance addressing blood glucose control after surgery.

Neurophysiological effects of various music genres on electroencephalographic (EEG) cerebral cortex activity

Background

Music has been associated with therapeutic properties for thousands of years across a vast number of diverse regions and cultures. This study expands upon our current understanding of music’s influence on human neurophysiology by investigating the effects of various music genres on cerebral cortex activity using electroencephalography (EEG).

Methods

A randomized, controlled study design was used. EEG data were recorded from 23 healthy adults, ages 19–28, while listening to a music sequence consisting of five randomized songs and two controls. The five studied music genres include: Classical, Tribal Downtempo, Psychedelic Trance (Psytrance), Goa Trance, and Subject Choice.

Results

Controls were associated with lower percentages of beta frequencies and higher percentages of alpha frequencies than the music genres. Psytrance was associated with higher percentages of theta and delta frequencies than the other music genres and controls. The lowest percentages of beta frequencies and highest percentages of alpha frequencies occurred in the occipital and parietal regions. The highest percentages of theta and delta frequencies occurred in the frontal and temporal regions. Subjects with prior music training exhibited increased percentages of delta frequencies in the frontal region. Subject gender and music preference did not have a significant influence on frequency band percentages.

Conclusions

Findings from this study support those of previous music therapy studies and provide novel insights regarding music’s influence on human neurophysiology. These findings also support the hypothesis that music may promote changes in cerebral cortex activity that have similarities to non-rapid eye movement (NREM) sleep, while the listener remains awake.

Severity of Preoperative HbA1c and Predicting Postoperative Complications in Spine Surgery

BACKGROUND

Diabetes mellitus (DM) is associated with a greater incidence of perioperative complications. The measurement of hemoglobin A1c (HbA1c) has not been routinely used in the preoperative assessment for spine surgeries.

METHODS

In the present single-institution, prospective study, HbA1c testing was included in the preoperative laboratory examination of patients undergoing spinal surgery from 2016 through 2018. The HbA1c levels were categorized using the American Diabetes Association guidelines as normal (HbA1c <5.7%), pre-DM (HbA1c 5.7%-6.4%), and diabetes (HbA1c >6.5%). Those with a HbA1c of ≥8% were separated as having poorly controlled DM for analysis. Perioperative complication and comorbidity data were collected to assess for associations with DM using logistic regression models. Odds ratios (ORs) and 95% confidence intervals were computed.

RESULTS

A total of 440 patients (238 men, mean age, 56.43 ± 13.28 years; mean body mass index, 30.80 ± 6.65 kg/m²) met the study criteria. The HbA1c was <5.7% in 206 patients (46.8%), 5.7%-6.4% in 148 (33.6%), 6.5%-7.9% in 64 (14.5%), and ≥8.0% in 23 patients (5.22%). Bivariate logistic modeling showed that patients with poorly controlled DM had a higher risk of complications (OR, 2.92) than did the patients with DM (OR, 2.13). Malignancy (OR, 2.62) and hypertension (OR, 1.86) were also significant risk factors for complications. However, smoking (OR, 0.83) was not significant. Poorly controlled DM remained associated with complications in multivariable logistic regression modeling (OR, 2.72).

CONCLUSIONS

Poorly control DM defined by the preoperative HbA1c was significantly associated with postoperative complications. Smoking, however, was not so associated. Preoperative HbA1c can be used to assess the risk of postoperative spine surgery complications.

Complex Multidisciplinary Cranial and Scalp Reconstruction for Patient Salvage

OBJECTIVE/BACKGROUND

Patients can develop scalp and cranial defects as a result of neoplasm, trauma, or infection. Reconstruction of these defects can be difficult in some patients and may require a multidisciplinary approach using creative solutions usually used for disease processes in other areas of the body, such as severe burns.

METHODS

A series of 9 patients were treated using multidisciplinary techniques for reconstruction of complex cranial and scalp defects. Data on patient characteristics, initial treatment, and preparatory and definitive reconstructive treatment were retrospectively collected. Outcomes were measured as full solution, partial solution, or failure.

RESULTS

Three patients had a full solution/wound closure, 5 had a partial solution, and 1 failed reconstructive attempt. Full solution patients tended to be younger, received reconstruction treatment modalities for longer periods of time, and had more definitive surgeries. Initial and preparatory surgeries did not tend to promote a full solution, though having fewer preparatory surgeries that were not related to wound vacuum-assisted closure use tended to be associated with a better outcome. Infection of the scalp or cranium did not tend to change the result.

CONCLUSIONS

Reconstructive salvage of complex cranial and scalp defects takes time, so patience and earlier recognition of need for atypical reconstruction is beneficial. Patient characteristics may influence outcomes, but judicious choice of materials and techniques is more critical to patient success. Use of a multidisciplinary approach to complex cranial and scalp reconstruction is a beneficial option for many patients for whom standard reconstruction methods are not viable.

Daily Lifestyle Modifications to Improve Quality of Life and Survival in Glioblastoma: A Review

Survival in glioblastoma remains poor despite advancements in standard-of-care treatment. Some patients wish to take a more active role in their cancer treatment by adopting daily lifestyle changes to improve their quality of life or overall survival. We review the available literature through PubMed and Google Scholar to identify laboratory animal studies, human studies, and ongoing clinical trials. We discuss which health habits patients adopt and which have the most promise in glioblastoma. While results of clinical trials available on these topics are limited, dietary restrictions, exercise, use of supplements and cannabis, and smoking cessation all show some benefit in the comprehensive treatment of glioblastoma. Marital status also has an impact on survival. Further clinical trials combining standard treatments with lifestyle modifications are necessary to quantify their survival advantages.

Isolated Primary Sinonasal Adenocarcinoma of the Sphenoid Sinus

Isolated lesions of the sphenoid sinus, particularly malignancies, are rarely reported and exist largely within the Otolaryngology literature. Delayed diagnosis may necessitate neurosurgical involvement; therefore, neurosurgeons must be aware of the range of pathologies in this region in order to provide adequate treatment. We present an unusual case of an 89-year-old female with several weeks of worsening headaches, vision loss, and cranial neuropathies. Work-up at an outside hospital was non-diagnostic. After referral, an expansive and erosive lesion within the left sphenoid sinus was identified. A transsphenoidal approach for resection of the lesion yielded a primary non-salivary non-intestinal type sinonasal adenocarcinoma, as well as bacterial sinusitis and probable allergic fungal sinusitis. The patient was treated with antimicrobial medications as well as stereotactic radiosurgery. Her neurological deficits did not improve with treatment, and she ultimately expired 3.5 months post-operatively after transition to hospice. Primary sinonasal adenocarcinoma is a very rare pathology in this location. Surgical intervention is necessary to obtain an accurate diagnosis and proceed with appropriate treatment. Delayed diagnosis likely portends a worse prognosis.

Pineal cysts: Does anyone need long-term follow up?

Pineal cysts are a common incidental finding on brain magnetic resonance imaging (MRI) whichfrequently prompts referral to neurosurgery. Currently, a management algorithm for patientswithout hydrocephalus, Parinaud's syndrome, or pineal apoplexy is lacking.We aimed to identifypredictive factors of pineal cyst volume change andsurgical intervention by performing retrospective chart review of 98 patients between 2005 and 2018 diagnosed with pineal cysts gleaned from our Neurosurgery clinical databases.We included patients whose initial and follow-up MRIs were available in our institutional radiology system or whose surgical pathology confirmed pineal cyst after evaluation with an initial MRI. Patients' medical records were queried for presenting symptoms, demographic, management, and pineal cyst measurements. Three dimensions (anterior-posterior, rostral-caudal, transverse) of pineal cyst size were measured and converted to cyst volume (cm³) for analysis. Fifty-five patients (mean age 26.09 ± 14.7 years) with pineal cysts met study criteria. Follow-up ranged from 4 months to 10 years. The indications for MR imaging included headache (81.8%) and vision problems (42%).Forty-eight patients who were observed had a mean volume change of 0.051 ± 0.862 cm [3] and median volume change of 0 cm [3] Patient symptoms, referral source, and age were not associated with changes in volume on follow-up. Aggregated number of symptoms did not differ between operative and observation patients. (p = 0.29). Pineal cyst volumes tend to remain stable over serial MR images, do not reliably correlate with symptoms, and do not typically require long-term follow-up.

Effect of Empiric Treatment of Asymptomatic Bacteriuria in Neurosurgical Trauma Patients on Surgical Site and Clostridium difficile Infection

BACKGROUND

Although empiric treatment of urinary tract colonized patients remains a frequent practice in neurosurgery, the value of this practice remains debatable.

OBJECTIVE

To analyze the effect of screening and treatment of bacteriuria on surgical site infections, incidence of Clostridium difficile, and mortality in neurosurgical trauma patients.

METHODS

Database queries and direct patient chart reviews were used to gather patient chart data. T-tests, chi-square tests, binary logistic regressions, and propensity matched cohorts comparisons were performed.

RESULTS

A total of 3563 admitted neurosurgical trauma patients were identified over an 8 yr period (1524 cranial, 1778 spinal, and 261 combined craniospinal diagnoses). Nine hundred ninety-one patients underwent an operative neurosurgical procedure. Urinalysis was significantly associated with antibiotics exposure in both operative and nonoperative patients (P < .001). Operative patients treated with empiric antibiotics did not have a reduced risk of wound infection (P = .21), including in a propensity matched cohort (P = .52). Patients treated with empiric antibiotics had significantly increased rates of C. difficile infection (P < .001). At last follow-up, neurosurgical trauma patients that developed C. difficile had an increased risk of death (P < .005); antibiotic exposure and death were also significantly associated (P = .018). The association of C. difficile with empiric antibiotics remained significant in a propensity-matched cohort (P = .0024).

CONCLUSION

The routine use of urinalysis and empiric urinary antibiotics for bacteriuria in neurosurgical trauma patients without urinary symptoms increases risk of exposure to antibiotics does not decrease rates of wound infection, and is associated with increased rates of C. difficile infection and death.

Does Surveillance-Detected Disease Progression Yield Superior Patient Outcomes in High-Grade Glioma?

BACKGROUND

Standard follow-up care for patients with high-grade glioma (HGG) involves routine surveillance imaging to detect disease progression, assess treatment response, and monitor clinical symptoms. Although logical in nature, evidence supporting this practice is limited. We hypothesize patients with tumor recurrence detected on routine surveillance imaging will experience superior outcomes relative to symptomatic detection, using measures of survival and postrecurrence neurologic function.

METHODS

Adult patients receiving treatment for HGG at our institution from 2004 to 2018 were identified, and data including tumor characteristics, imaging results, neurologic status, and survival were extracted from the medical records of patients meeting inclusion criteria. All participants were followed for a minimum of 12 months, or for survival duration. Survival and neurologic function differences were assessed using log rank and 2-sample t tests with 2-sided 0.05 alpha level of significance.

RESULTS

Of the 74 patients meeting inclusion criteria, 47 (63.5%) had recurrence detected via routine surveillance imaging, and 27 (36.5%) had symptomatic detection outside of the surveillance schedule. Neither median overall survival (14.8 months for surveillance and 15.7 months for symptomatic; P = 0.600) nor postrecurrence neurologic function (assessed by Karnofsky Performance Scale Index and Eastern Cooperative Oncology Group) differed between the surveillance and symptomatic detection groups (P = 0.699 and P = 0.908, respectively).

CONCLUSIONS

Recurrence detection occurring via routine surveillance imaging did not yield superior patient outcomes relative to symptomatic detection occurring outside of the standard surveillance schedule in patients with HGG. Further evaluation of surveillance imaging and alternative follow-up methods for this patient population may be warranted.

Potential effects of nicotine on glioblastoma and chemoradiotherapy: a review

Introduction: Glioblastoma multiforme (GBM) has a poor prognosis despite maximal surgical resection with subsequent multi-modal radiation and chemotherapy. Use of tobacco products following diagnosis and during the period of treatment for non-neural tumors detrimentally affects treatment and prognosis. Approximately, 16-28% of patients with glioblastoma continue to smoke after diagnosis and during treatment. The literature is sparse for information-pertaining effects of smoking and nicotine on GBM treatment and prognosis. Areas covered: This review discusses cellular pathways involved in GBM progression that might be affected by nicotine, as well as how nicotine may contribute to resistance to treatment. Similarities of GBM pathways to those in non-neural tumors are investigated for potential effects by nicotine. English language papers were identified using PubMed, Medline and Scopus databases using a combination of keywords including but not limited to the following: nicotine, vaping, tobacco, e-cigarettes, smoking, vaping AND glioblastoma or brain cancer OR/AND temozolomide, carmustine, methotrexate, procarbazine, lomustine, vincristine, and neural tumor cell lines. Expert opinion: Understanding the impact of nicotine on treatment and resistance to chemotherapeutics should allow physicians to educate their patients with GBM with evidence-based recommendations about the effects of continuing to use nicotine-containing products after diagnosis and during treatment.

Effects of platelet dysfunction and platelet transfusion on outcomes in traumatic brain injury patients

OBJECTIVE

Platelet inhibition in traumatic brain injury (TBI) may be due to injury or antiplatelet medication use pre-injury. This study aims to identify factors associated with increased platelet arachidonic acid (AA) and adenosine diphosphate (ADP) inhibition and determine if platelet transfusion reduces platelet dysfunction and affects outcome.

METHODS

Prospective thromboelastography (TEG) assays were collected on adult patients with TBI with intracranial injuries detected by computed tomography (CT). Outcomes included in-hospital mortality, and CT lesion expansion.

RESULTS

Of 153 patients, ADP inhibition was increased in moderate and severe TBI compared to mild TBI (p = 0.0011). P2Y12 inhibiting medications had increased ADP inhibition (p = 0.0077). Admission ADP inhibition was not associated with in-hospital mortality (p = 0.24) or CT lesion expansion (p = 0.94). Mean reduction of ADP inhibition from platelet transfusion (-15.1%) relative to no transfusion (+ 11.7%) was not statistically different (p = 0.0472).

CONCLUSIONS

Mild TBI results in less ADP inhibition compared to moderate and severe TBI, suggesting a dose response relationship between TBI severity and degree of platelet dysfunction. Further, study is warranted to determine efficacy and parameters for platelet transfusion in patients with TBI.

Do Anti-Oxidants Vitamin D3, Melatonin, and Alpha-Lipoic Acid Have Synergistic Effects with Temozolomide on Cultured Glioblastoma Cells?

Background: Cancer patients often take over-the-counter anti-oxidants as primary treatment or in combination with chemotherapy. Data about such use in glioblastoma is limited. Methods: Cultured U87-MG cells, a primary glioblastoma cell line (MU1454), U87-MG derived stem-like cells (scU87), and MU1454 derived stem-like cell lines (scMU1454) were pre-treated with one of three anti-oxidants—Vitamin D₃, Melatonin, and alpha-lipoic acid (LA)—for 72 h, followed by a 72 h treatment with temozolomide (TMZ). MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assessed cell proliferation. DCFDA Cellular ROS Detection Assay and Glutathione peroxidase (GP×1) activity assessed the anti-oxidant effect of TMZ +/− an anti-oxidant drug. Results: Vitamin D₃ did not affect MU1454, but had slight TMZ synergism for U87-MG. Melatonin 1 mM decreased U87-MG and MU1454 cell proliferation. As pretreatment to TMZ, melatonin 1 mM and 50 nM significantly reduced proliferation. LA 1 mM had a significant effect alone or with TMZ on U87-MG and MU1454. LA 250 uM also reduced proliferation by almost 50%. Melatonin and LA significantly enhanced the responsiveness of scMU1454 to TMZ, while Melatonin 50 nM exerted similar effects on scU87. The anti-oxidants were associated with generally decreased reactive oxygen species and limited GP×1 effects. Conclusions: Anti-oxidants may have synergistic effects with TMZ. LA offers the most promise, followed by melatonin.

An Unusual Presentation of a Cervical Paraspinal Leiomyoma in an Adolescent Female

Objective We describe an apparently unique case of an extra-uterine leiomyoma in the cervical paraspinal tissue including its evaluation and management. Methods A 14-year-old girl was referred to the neurology clinic for an abnormal head CT following a concussion. MRI revealed a homogenously enhancing left cervical paraspinal mass. The patient underwent complete resection and subsequent genetic testing and counseling were obtained to determine the presence of Li-Fraumeni Syndrome (LFS) or Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC) mutations. Result Histopathological examination proved that the tumor was a benign leiomyoma. Genomic testing for Fumarate Hydratase Gene, HLRCC, TP53 mutations or deletions, and LFS sequencing were negative. Further testing showed no immunosuppression. Conclusions To the best of our knowledge, this is the only case of paraspinal leiomyoma to have been reported to date. We emphasize the importance of considering immunosuppression, LFS, or HLRCC as an underlying cause in extra-uterine leiomyata.

Coagulopathy in the Setting of Mild Traumatic Brain Injury: Truths and Consequences

Mild traumatic brain injury (mTBI) is a common, although poorly-defined clinical entity. Despite its initially mild presentation, patients with mTBI can rapidly deteriorate, often due to significant expansion of intracranial hemorrhage. TBI-associated coagulopathy is the topic of significant clinical and basic science research. Unlike trauma-induced coagulopathy (TIC), TBI-associated coagulopathy does not generally follow widespread injury or global hypoperfusion, suggesting a distinct pathogenesis. Although the fundamental mechanisms of TBI-associated coagulopathy are far from clearly elucidated, several candidate molecules (tissue plasminogen activator (tPA), urokinase plasminogen activator (uPA), tissue factor (TF), and brain-derived microparticles (BDMP)) have been proposed which might explain how even minor brain injury can induce local and systemic coagulopathy. Here, we review the incidence, proposed mechanisms, and common clinical tests relevant to mTBI-associated coagulopathy and briefly summarize our own institutional experience in addition to identifying areas for further research.

Radiosurgery to the Postoperative Tumor Bed for Metastatic Carcinoma Versus Whole Brain Radiation After Surgery

Background

The treatment paradigm from postoperative whole brain radiation therapy (WBRT) to post-operative stereotactic radiosurgery (SRS) to the tumor bed has shifted with little data to evaluate whether each treatment modality confers equivalent tumor control and survival outcomes.

Methods

Patients with surgical resection of single brain metastases from January 2010 to December 2014 were treated postoperatively with either WBRT or SRS. Retrospective patient data was compared for local control, distant brain recurrence, overall survival, and radiation complications.

Results

Forty-six received WBRT, and 37 received tumor bed SRS. Twelve of 35 (34%) SRS patients experienced local recurrence compared to 17 of 31 (55%) WBRT patients (p = 0.09). The median survival was 440 days (14.7 months) for SRS and 202 days (6.7 months) for WBRT (p = 0.062, log-rank). SRS demonstrated improved survival benefit in the first six months (p = 0.0034; Wilcoxon). Radiation-related adverse changes after SRS (22%) were not statistically different from WBRT (8.7%) (p = 0.152). Age (p = 0.08), systemic cancer status (p = 0.30), Graded Prognostic Assessment (p = 0.28), number of brain metastases at diagnosis (p = 0.65), tumor volume at diagnosis (p = 0.13), new brain lesions (p = 0.74) and neurologic versus systemic cause of death (p = 0.11) did not differ between the groups.

Conclusions

Following surgical resection, tumor bed SRS can be used effectively in lieu of WBRT to treat brain metastases with comparable local control and distant control and without significantly more adverse events.

The effects of anaemia and transfusion on patients with traumatic brain injury: A review

BACKGROUND

Anaemia in traumatic brain injury (TBI) is frequently encountered. Neurosurgical texts continue to recommend transfusion for hematocrit below 30%, despite clear evidence to do so. Transfusion should increase oxygen delivery to the brain, but it may also increase morbidity and mortality.

METHODS

This study reviewed the relevant literature to better understand the risks of anaemia and benefits of correction of anaemia by transfusion.

RESULTS

Of the 21 studies reviewed, eight found that anaemia was harmful to patients with TBI; five found no significant outcome; seven found transfusion was associated with higher rates of morbidity and mortality; two found that transfusion lowered mortality and increased brain tissue oxygen levels; and ten found no correlation between transfusion and outcome. However, the levels of anaemia severity and the outcome measurements varied widely and the majority of outcomes focused on crude measurements rather than detailed functional assessments.

CONCLUSIONS

No division of response based on gender difference or impact of anaemia in the post-hospital treatment setting was observed. A randomized control trial is recommended to determine the impact of anaemia and transfusion on detailed outcome assessment in comparison of transfusion thresholds ranging from ≤ 7 g dL^-1 to ≤ 9 g dL^-1 in patients with moderate-to-severe TBI.

Identification of Global DNA Methylation Signatures in Glioblastoma-Derived Cancer Stem Cells

Glioblastoma (GBM) is the most common and most aggressive primary brain tumor in adults. The existence of a small population of stem-like tumor cells that efficiently propagate tumors and resist cytotoxic therapy is one proposed mechanism leading to the resilient behavior of tumor cells and poor prognosis. In this study, we performed an in-depth analysis of the DNA methylation landscape in GBM-derived cancer stem cells (GSCs). Parallel comparisons of primary tumors and GSC lines derived from these tumors with normal controls (a neural stem cell (NSC) line and normal brain tissue) identified groups of hyper- and hypomethylated genes that display a trend of either increasing or decreasing methylation levels in the order of controls, primary GBMs, and their counterpart GSC lines, respectively. Interestingly, concurrent promoter hypermethylation and gene body hypomethylation were observed in a subset of genes including MGMT, AJAP1 and PTPRN2. These unique DNA methylation signatures were also found in primary GBM-derived xenograft tumors indicating that they are not tissue culture-related epigenetic changes. Integration of GSC-specific epigenetic signatures with gene expression analysis further identified candidate tumor suppressor genes that are frequently down-regulated in GBMs such as SPINT2, NEFM and PENK. Forced re-expression of SPINT2 reduced glioma cell proliferative capacity, anchorage independent growth, cell motility, and tumor sphere formation in vitro. The results from this study demonstrate that GSCs possess unique epigenetic signatures that may play important roles in the pathogenesis of GBM.

Successful treatment of dysgeusia after middle-ear surgery with amitriptyline: Case report

INTRODUCTION

The chorda tympani branches off of the facial nerve within the petrous portion of the temporal bone, and is responsible for controlling the taste in the anterior two-thirds of the tongue on each side. Due to its location, it is commonly injured during middle-ear surgery resulting in dysgeusia.

METHOD

A case of a 59-year-old male had recurrent otitis media resulting in tympanic membrane perforation. Patient subsequently underwent lateral graft tympanoplasty. Shortly after surgery patient reported onset of dysgeusia consisting of metallic taste at the tip of the tongue and salty taste on the left side of the tongue.

RESULTS

Treatment with Amitriptyline 50mg each night significantly improved the patient's symptoms of dysgeusia.

CONCLUSIONS

Amitriptyline may be an effective treatment for dysgeusia occurring after middle-ear surgery.

Neural stem/progenitor cells react to non-glial cns neoplasms

It is well established that the normal human brain contains populations of neural stem/progenitor cells. Recent studies suggest that they migrate toward a variety of CNS tissue injuries. In an investigation of the potential role of neural stem cells in the pathogenesis of primary CNS lymphomas (NHL-CNS), we observed that neural stem/progenitor cells appeared to accumulate at the border of the tumors with the brain and in the advancing edge of the tumors, in a pattern similar to that seen with reactive gliosis. We identified neural stem/progenitor cells using standard immunohistochemical markers thereof, including CD133, nestin, Group II Beta-tubulin, Musashi1, and the transcription factor Sox2, in neurosurgically obtained specimens of NHL-CNS metastatic carcinoma , and metastatic melanoma . We had similar results with each of these markers but found that Sox2 antibodies provided the clearest and most robust labeling of the cells at the borders of these non-glial tumors. To exclude that the immunoreactive cells were actually neoplastic, double-label immunohistochemistry for Sox2 and CD20 (for NHL-CNS), Sox2 and cytokeratin (CAM5.2, for carcinomas), or Sox2 and HMB45 (for melanomas) showed that in each tumor type, Sox2-immunoreactive cells adjacent to and among the tumor cells were separate from neoplastic cells. Sox2/GFAP double-labeling revealed a consistent pattern of Sox2 immunopositivity both in reactive GFAP-immunopositive astrocytes and in GFAP-negative cells, at the interface of tumor and non-neoplastic brain. These results suggest that neural stem/progenitor cells migrate to non-glial neoplasms in the CNS, are a source of reactive astrocytes, and that Sox2 is a reliable immunohistochemical marker for these cells.

Leukoencephalopathy, cerebral calcifications, and cysts in two sisters

BACKGROUND

The triad of leukoencephalopathy with cerebral calcifications and cysts is a rare syndrome consisting of these three radiographic findings first described by Labrune et al. in 1996. The inheritance pattern and genetic mutation responsible for this syndrome (if any) have not been determined.

PATIENT DESCRIPTION

We report the occurrence of this syndrome in siblings. Two sisters presented with leukoencephalopathy, cerebral calcifications, and cysts approximately 10 years apart, one at 18 years with longstanding epilepsy and the other at 25 years with postpartum stroke-like signs. In both individuals, computed tomography revealed calcifications in the basal ganglia and subcortical white matter as well as supratentorial cysts. Magnetic resonance imaging demonstrated diffuse white matter increased T2 signal and bilateral supratentorial cysts with enhancing walls. Both patients underwent biopsy, one an open biopsy and the other a stereotactic biopsy, with sections of the resected tissue revealing gliosis with Rosenthal fibers, myelin loss, and calcifications, plus in the larger sample cystic spaces and thick-walled abnormal blood vessels with hemosiderin deposition in the adjacent tissues.

CONCLUSION

In these siblings, the triad of radiological findings, histopathologic findings, and lack of extraneurological findings on physical examination suggest an occurrence of familial leukoencephalopathy, cerebral calcifications, and cysts with probable autosomal recessive inheritance.

Abstract 1379: Identification of global DNA methylation signatures in glioblastoma-derived cancer stem cells

Glioblastoma (GBM) is the most common and most aggressive brain tumor in adults. Its frequent recurrence after resection and dismal prognosis are thought to be due to a small population of stem-like tumor cells that efficiently propagate tumors and resist cytotoxic therapy. In this study, we performed an in depth analysis of the DNA methylation landscape in GBM-derived cancer stem cells (GSCs). Parallel comparisons of primary GBM tumors and GSC lines derived from these tumors with normal controls (a neural stem cell (NSC) line and normal brain tissue) identified two groups hyper- and hypomethylated of genes that display a trend of either increasing or decreasing methylation levels in the order of controls, primary GBMs, and their counterpart GSC lines, respectively. Interestingly, concurrent promoter hypermethylation and gene body hypomethylation were observed in a subset of genes including MGMT, AJAP1 and PTPRN2. These unique DNA methylation signatures were also be found in primary GBM-derived xenograft tumors suggesting that they were not tissue culture-related epigenetic changes. Integration of GSC-specific epigenetic signatures with gene expression analysis further identified candidate tumor suppressor genes that are frequently down regulated in GBMs such as SPINT2, NEFM, and PENK. The comparison between the NSC line and the normal brain tissue sample leads to the identification of a group of NSC-specific differentially methylated regions (nsDMRs). Cluster analysis using nsDMRs revealed the presence of stem cell-specific DNA methylation signatures in both primary GBM and GSC lines. Higher expression of genes associated with stem cell-specific DNA methylation signatures such as DNMT3A, STAT5A, CSTB, PMEPA1 and G6PD in GBM patients was found to be associated with poor patient survival. The results from this study demonstrate the utility of using cancer stem cell models for advancing understanding of the pathobiology of gliomas.

Citation Format: Eun Joon Lee, Prakash Rath, Jimei Liu, Dungsheng Ryu, Alan Free, Lirong Pei, Douglas C Anthony, Suash Sharma, Mark D Kirk, John J. Laterra, Duck Hwan Ryu, Jeong-Hyeon Choi, Huidong Shi, Douglas C. Miller, N. Scott Litofsky, Qi Feng. Identification of global DNA methylation signatures in glioblastoma-derived cancer stem cells. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1379. doi:10.1158/1538-7445.AM2014-1379

Use of the Electronic Health Record to Track Continuity of Care in Neurological Surgery Residency

BACKGROUND

Continuity of care in neurological surgery includes preoperative planning, technical and cognitive operative experience, and postoperative follow-up. Determining the extent of continuity of care with duty hour limits is problematic.

OBJECTIVE

We used electronic health record data to track continuity of care in a neurological surgery program and to assess changes in rotation requirements.

METHODS

The electronic health record was surveyed for all dictated resident-neurological surgery patient encounters (excluding progress notes), discharge summaries, and bedside procedures (July 2009-November 2011). Encounters were designated as preoperative, operative, or postoperative and were grouped by postgraduate year (PGY)-1 through PGY-6.

RESULTS

A total of 6382 dictations were reviewed, with 5231 (82.0%) pertinent to neurological surgery. Of the 1469 operative notes, 303 (20.6%) had a record of an encounter with the operating resident in either a postoperative or preoperative setting. Preoperative encounters totaled 10.1% (148 of 1469); postoperative, 5.1% (75 of 1469); and encounters with both were 5.4% (80 of 1469). Continuity of care was as follows: PGY-1, 13.8% (4 of 29); PGY-2, 17.4% (26 of 149); PGY-3, 29.0% (36 of 124); PGY-4, 24.8% (73 of 294); PGY-5, 28.8% (109 of 379); and PGY-6, 11.1% (55 of 494). One of the highest continuity rates was observed in a rotation specifically constructed to enhance continuity of care.

CONCLUSIONS

The electronic health record can be used to track resident continuity of care in neurological surgery. The primary operating resident saw the patient in nonoperative settings, such as general admission, clinic visitation, or consultation in 20.6% (303 of 1469) of cases.

Safety and efficacy of early thromboembolism chemoprophylaxis after intracranial hemorrhage from traumatic brain injury

OBJECT

Patients with traumatic brain injury (TBI) are at risk for development of thromboembolic disease. The use of chemoprophylaxis in this patient group has not fully been characterized. The authors hypothesize that early chemoprophylaxis in patients with TBI is safe and efficacious.

METHODS

In May 2009, a protocol was instituted for patients with TBI where chemoprophylaxis for thromboembolic disease (either 30 mg of Lovenox twice daily or 5000 U of heparin 3 times a day) was initiated 24 hours after an intracranial hemorrhage (ICH) was demonstrated as stable on head CT image. Two cohorts were evaluated: Cohort A included patients from May 2008 through April 2009 who had no routine administration of chemoprophylaxis, and Cohort B included patients from May 2009 through May 2010 after the protocol was instituted. The groups were compared, with the major outcomes being deep venous thrombosis (DVT), pulmonary embolism, and increase in size of ICH.

RESULTS

Of the 312 patients with TBI who were seen during the study course, 236 patients met criteria for inclusion in the study: 107 patients in Cohort A and 129 patients in Cohort B. The DVT rate was 6 occurrences (5.61%) in Cohort A and 0 occurrences (0%) in Cohort B, which was a statistically significant difference (p = 0.0080). Pulmonary embolism was found in 4 patients (3.74%) in Cohort A and 1 patient (0.78%) in Cohort B, a difference that did not reach statistical significance (p = 0.18). Three instances (2.8%) in Cohort A and 1 instance (0.7%) in Cohort B of increased ICH occurred after starting anticoagulation for chemoprophylaxis; this was not statistically different (p = 0.33).

CONCLUSIONS

Use of chemoprophylaxis in TBI 24 hours after stable head CT is safe and decreases the rate of DVT formation.

Isolation and characterization of a population of stem-like progenitor cells from an atypical meningioma

The majority of meningiomas are benign tumors associated with favorable outcomes; however, the less common aggressive variants with unfavorable outcomes often recur and may be due to subpopulations of less-differentiated cells residing within the tumor. These subpopulations of tumor cells have tumor-initiating properties and may be isolated from heterogeneous tumors when sorted or cultured in defined medium. We report the isolation and characterization of a population of tumor-initiating cells derived from an atypical meningioma. We identify a tumor-initiating population from an atypical meningioma, termed meningioma-initiating cells (MICs). These MICs self-renew, differentiate, and can recapitulate the histological characteristics of the parental tumor when transplanted at 1000 cells into the flank regions of athymic nude mice. Immunohistochemistry reveals stem-like protein expression patterns similar to neural stem and progenitor cells (NSPCs) while genomic profiling verified the isolation of cancer cells (with defined meningioma chromosomal aberrations) from the bulk tumor. Microarray and pathway analysis identifies biochemical processes and gene networks related to aberrant cell cycle progression, particularly the loss of heterozygosity of tumor suppressor genes CDKN2A (p16(INK4A)), p14(ARF), and CDKN2B (p15(INK4B)). Flow cytometric analysis revealed the expression of CD44 and activated leukocyte adhesion molecule (ALCAM/CD166); these may prove to be markers able to identify this cell type. The isolation and identification of a tumor-initiating cell population capable of forming meningiomas demonstrates a useful model for understanding meningioma development. This meningioma model may be used to study the cell hierarchy of meningioma tumorogenesis and provide increased understanding of malignant progression.

Salmonella brain abscess in a patient on chronic azathioprine therapy for myasthenia gravis: report of an unusual case and review of literature in the postantibiotic era

Focal intracranial infections caused by Salmonella species in adults are exceedingly uncommon. Structural brain injury with coexisting immunocompromised status appears to predispose adults to this rare manifestation of Salmonella infection. We report a case of Salmonella brain abscess in a patient with myasthenia gravis on chronic azathioprine therapy without any prior structural brain lesion. We reviewed world literature and discuss their analysis of Salmonella brain abscess in adult population in the postantibiotic era.

Optimizing referral practices for patients with non-traumatic intracerebral hemorrhage

Because many cases of non-traumatic intracerebral hemorrhage (NTICH) do not require surgery, establishing the most appropriate referral and treatment algorithms to optimize patient outcome, including appropriate utilization of specialty physicians, such as neurosurgeons and neurologists, would be helpful. In this retrospective study based on census and billing records, the best referral model showed that medical therapy was the chosen treatment option if patients did not meet all of the following three criteria: GCS < or = 13, age < or = 70 and lesion volume > or = 40 cm3. These criteria may be helpful in predicting the need for surgery and improving referral practices for patients with NTICH.

Stem cells as vectors to deliver HSV/tk gene therapy for malignant gliomas

The prognosis of patients diagnosed with malignant gliomas including glioblastoma multiforme (GBM) is poor and there is an urgent need to develop and translate novel therapies into the clinic. Neural stem cells display remarkable tropism toward GBMs and thus may provide a platform to deliver oncolytic agents to improve survival. First we provide a brief review of clinical trials that have used intra-tumoral herpes simplex virus thymidine kinase (HSV/tk) gene therapy to treat brain tumors. Then, we review recent evidence that neural stem cells can be used to deliver HSV/tk to GBMs in animal models. While previous clinical trials used viruses or non-migratory vector-producing cells to deliver HSV/tk, the latter approaches were not effective in humans, primarily because of satellite tumor cells that escaped surgical resection and survived due to low efficiency delivery of HSV/tk. To enhance delivery of HSV/tk to kill gliomas cells, recent animal studies have focused on the ability of neural stem cells, transduced with HSV/tk, to migrate efficiently and selectively to regions occupied by GBM cells. This approach holds the promise of targeting GBM cells that have infiltrated the brain well beyond the original site of the tumor epicenter.