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Tabor JK, Dincer A, O'Brien J, Lei H, Vetsa S, Vasandani S, Jalal MI, Yalcin K, Morales-Valero SF, Marianayagam N, Alanya H, Elsamadicy AA, Millares Chavez MA, Aguilera SM, Mishra-Gorur K, McGuone D, Fulbright RK, Jin L, Erson-Omay EZ, Günel M, Moliterno J. Variations in the genomic profiles and clinical behavior of meningioma by racial and ethnic group. J Neurosurg 2024:1-9. [PMID: 38518289 DOI: 10.3171/2024.1.jns231633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/09/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE The influence of socioeconomic factors on racial disparities among patients with sporadic meningiomas is well established, yet other potential causative factors warrant further exploration. The authors of this study aimed to determine whether there is significant variation in the genomic profile of meningiomas among patients of different races and ethnicities and its correlation with clinical outcomes. METHODS The demographic, genomic, and clinical data of patients aged 18 years and older who had undergone surgery for sporadic meningioma between September 2008 and November 2021 were analyzed. Statistical analyses were performed to detect differences across all racial/ethnic groups, as were direct comparisons between Black and non-Black groups plus Hispanic and non-Hispanic groups. RESULTS This study included 460 patients with intracranial meningioma. Hispanic patients were significantly younger at surgery (53.9 vs 60.2 years, p = 0.0006) and more likely to show symptoms. Black patients had a higher incidence of anterior skull base tumors (OR 3.2, 95% CI 1.7-6.3, p = 0.0008) and somatic hedgehog mutations (OR 5.3, 95% CI 1.6-16.6, p = 0.003). Hispanics were less likely to exhibit the aggressive genomic characteristic of chromosome 1p deletion (OR 0.28, 95% CI 0.07-1.2, p = 0.06) and displayed higher rates of TRAF7 somatic driver mutations (OR 2.96 95% CI 1.1-7.8, p = 0.036). Black patients had higher rates of recurrence (OR 2.6, 95% CI 1.3-5.2, p = 0.009) and shorter progression-free survival (PFS; HR 2.9, 95% CI 1.6-5.4, p = 0.002) despite extents of resection (EORs) similar to those of non-Black patients (p = 0.745). No significant differences in overall survival were observed among groups. CONCLUSIONS Despite similar EORs, Black patients had worse clinical outcomes following meningioma resection, characterized by a higher prevalence of somatic hedgehog mutations, increased recurrence rates, and shorter PFS. Meanwhile, Hispanic patients had less aggressive meningiomas, a predisposition for TRAF7 mutations, and no difference in PFS. These findings could inform the care and treatment strategies for meningiomas, and they establish the foundation for future studies focusing on the genomic origins of these observed differences.
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Affiliation(s)
- Joanna K Tabor
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Alper Dincer
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
- 3Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts
| | - Joseph O'Brien
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Haoyi Lei
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Shaurey Vetsa
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Sagar Vasandani
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Muhammad I Jalal
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Kanat Yalcin
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Saul F Morales-Valero
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Neelan Marianayagam
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Hasan Alanya
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | | | | | - Stephanie M Aguilera
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Ketu Mishra-Gorur
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Declan McGuone
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
- 4Pathology
| | - Robert K Fulbright
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
- 6Radiology and Biomedical Imaging, Neuroradiology Section, Yale School of Medicine, New Haven, Connecticut
| | - Lan Jin
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - E Zeynep Erson-Omay
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Murat Günel
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
- 5Genetics, and
| | - Jennifer Moliterno
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
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2
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Tabor JK, O'Brien J, Vasandani S, Vetsa S, Lei H, Jalal MI, Marianayagam NJ, Jin L, Millares Chavez M, Haynes J, Dincer A, Yalcin K, Aguilera SM, Omay SB, Mishra-Gorur K, McGuone D, Morales-Valero SF, Fulbright RK, Gunel M, Erson-Omay EZ, Moliterno J. Clinical and genomic differences in supratentorial versus infratentorial NF2 mutant meningiomas. J Neurosurg 2023; 139:1648-1656. [PMID: 37243548 DOI: 10.3171/2023.4.jns222929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/11/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Mutations in NF2 are the most common somatic driver mutation in sporadic meningiomas. NF2 mutant meningiomas preferentially arise along the cerebral convexities-however, they can also be found in the posterior fossa. The authors investigated whether NF2 mutant meningiomas differ in clinical and genomic features based on their location relative to the tentorium. METHODS Clinical and whole exome sequencing (WES) data for patients who underwent resection of sporadic NF2 mutant meningiomas were reviewed and analyzed. RESULTS A total of 191 NF2 mutant meningiomas were included (165 supratentorial, 26 infratentorial). Supratentorial NF2 mutant meningiomas were significantly associated with edema (64.0% vs 28.0%, p < 0.001); higher grade-i.e., WHO grade II or III (41.8% vs 3.9%, p < 0.001); elevated Ki-67 (55.0% vs 13.6%, p < 0.001); and larger volume (mean 45.5 cm3 vs 14.9 cm3, p < 0.001). Furthermore, supratentorial tumors were more likely to harbor the higher-risk feature of chromosome 1p deletion (p = 0.038) and had a larger fraction of the genome altered with loss of heterozygosity (p < 0.001). Infratentorial meningiomas were more likely to undergo subtotal resection than supratentorial tumors (37.5% vs 15.8%, p = 0.021); however, there was no significant difference in overall (p = 0.2) or progression-free (p = 0.4) survival. CONCLUSIONS Supratentorial NF2 mutant meningiomas are associated with more aggressive clinical and genomic features as compared with their infratentorial counterparts. Although infratentorial tumors have higher rates of subtotal resection, there is no associated difference in survival or recurrence. These findings help to better inform surgical decision-making in the management of NF2 mutant meningiomas based on location, and may guide postoperative management of these tumors.
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Affiliation(s)
- Joanna K Tabor
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Joseph O'Brien
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Sagar Vasandani
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Shaurey Vetsa
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Haoyi Lei
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Muhammad I Jalal
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Neelan J Marianayagam
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Lan Jin
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | | | | | - Alper Dincer
- 3Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts
| | - Kanat Yalcin
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Stephanie M Aguilera
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | | | - Ketu Mishra-Gorur
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Declan McGuone
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
- 4Pathology
| | - Saul F Morales-Valero
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Robert K Fulbright
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
- 5Radiology and Biomedical Imaging, and
| | - Murat Gunel
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
- 6Genetics, Yale School of Medicine, New Haven, Connecticut
| | - E Zeynep Erson-Omay
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
| | - Jennifer Moliterno
- Departments of1Neurosurgery
- 2The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut; and
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Morales-Valero SF, Tabor JK, Moliterno J. Microvascular Decompression for Treatment of Simultaneous Arterial and Venous Conflict Causing Trigeminal Neuralgia: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e291. [PMID: 37499238 DOI: 10.1227/ons.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/31/2023] [Indexed: 07/29/2023] Open
Affiliation(s)
- Saul F Morales-Valero
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, USA
| | - Joanna K Tabor
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, USA
| | - Jennifer Moliterno
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut, USA
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Qureshi HM, Tabor JK, Pickens K, Lei H, Vasandani S, Jalal MI, Vetsa S, Elsamadicy A, Marianayagam N, Theriault BC, Fulbright RK, Qin R, Yan J, Jin L, O'Brien J, Morales-Valero SF, Moliterno J. Frailty and postoperative outcomes in brain tumor patients: a systematic review subdivided by tumor etiology. J Neurooncol 2023; 164:299-308. [PMID: 37624530 PMCID: PMC10522517 DOI: 10.1007/s11060-023-04416-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/06/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE Frailty has gained prominence in neurosurgical oncology, with more studies exploring its relationship to postoperative outcomes in brain tumor patients. As this body of literature continues to grow, concisely reviewing recent developments in the field is necessary. Here we provide a systematic review of frailty in brain tumor patients subdivided by tumor type, incorporating both modern frailty indices and traditional Karnofsky Performance Status (KPS) metrics. METHODS Systematic literature review was performed using PRISMA guidelines. PubMed and Google Scholar were queried for articles related to frailty, KPS, and brain tumor outcomes. Only articles describing novel associations between frailty or KPS and primary intracranial tumors were included. RESULTS After exclusion criteria, systematic review yielded 52 publications. Amongst malignant lesions, 16 studies focused on glioblastoma. Amongst benign tumors, 13 focused on meningiomas, and 6 focused on vestibular schwannomas. Seventeen studies grouped all brain tumor patients together. Seven studies incorporated both frailty indices and KPS into their analyses. Studies correlated frailty with various postoperative outcomes, including complications and mortality. CONCLUSION Our review identified several patterns of overall postsurgical outcomes reporting for patients with brain tumors and frailty. To date, reviews of frailty in patients with brain tumors have been largely limited to certain frailty indices, analyzing all patients together regardless of lesion etiology. Although this technique is beneficial in providing a general overview of frailty's use for brain tumor patients, given each tumor pathology has its own unique etiology, this combined approach potentially neglects key nuances governing frailty's use and prognostic value.
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Affiliation(s)
- Hanya M Qureshi
- Department of Neurological Surgery, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Joanna K Tabor
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Kiley Pickens
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Haoyi Lei
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Sagar Vasandani
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Muhammad I Jalal
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Shaurey Vetsa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Aladine Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Neelan Marianayagam
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Brianna C Theriault
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Robert K Fulbright
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Ruihan Qin
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Jiarui Yan
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Lan Jin
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Joseph O'Brien
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Saul F Morales-Valero
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Jennifer Moliterno
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA.
- The Chênevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA.
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Lei H, Tabor JK, O'Brien J, Qin R, Pappajohn AF, Chavez MAM, Morales-Valero SF, Moliterno J. Associations of race and socioeconomic status with outcomes after intracranial meningioma resection: a systematic review and meta-analysis. J Neurooncol 2023; 163:529-539. [PMID: 37440095 DOI: 10.1007/s11060-023-04393-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/06/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE Social determinants of health broadly affect healthcare access and outcomes. Studies report that minorities and low socioeconomic status (SES) patients undergoing intracranial meningioma resection demonstrate worse outcomes and higher mortality rates. This systematic review and meta-analysis summarizes the available research reporting racial and SES disparities in intracranial meningioma resection outcomes. METHODS A systematic review was conducted using PRISMA guidelines and included peer-reviewed, English-language articles from the United States between 2000 and 2022 that reported racial and SES disparities in meningioma outcomes. Outcomes included overall survival (OS), extent of resection (EOR), hospitalization costs, length of stay (LOS), 30-day readmission, recurrence, and receipt of surgery and adjuvant radiotherapy. A quantitative meta-analysis was performed only on survival outcomes by race. All other variables were summarized as a systematic review. RESULTS 633 articles were identified; 19 studies met inclusion criteria. Black or low SES patients were more likely to have increased hospitalization costs, rates of 30-day readmission, LOS, recurrence and less likely to undergo surgery, gross total resection, and adjuvant radiotherapy for their tumors. Six studies were used for the quantitative meta-analysis of race and OS. Compared to White patients, Black patients had significantly worse survival outcomes, and Asian patients had significantly better survival outcomes. CONCLUSION Disparities in outcomes exist for patients who undergo surgery for meningioma, such that Black and low SES patients have worse outcomes. The literature is quite sparse and contains confounding relationships not often accounted for appropriately. Further studies are needed to help understand these disparities to improve outcomes.
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Affiliation(s)
- Haoyi Lei
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Joanna K Tabor
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Joseph O'Brien
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Ruihan Qin
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Alexandros F Pappajohn
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Miguel A Millares Chavez
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Saul F Morales-Valero
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Jennifer Moliterno
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA.
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA.
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Dincer A, Morales-Valero SF, Robert SM, Tabor JK, O'Brien J, Yalcin K, Fulbright RK, Erson-Omay Z, Dunn IF, Moliterno J. Surgical strategies for intracranial meningioma in the molecular era. J Neurooncol 2023; 162:253-265. [PMID: 37010677 PMCID: PMC10167142 DOI: 10.1007/s11060-023-04272-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 02/16/2023] [Indexed: 04/04/2023]
Abstract
INTRODUCTION Surgical resection has long been the treatment of choice for meningiomas and is considered curative in many cases. Indeed, the extent of resection (EOR) remains a significant factor in determining disease recurrence and outcome optimization for patients undergoing surgery. Although the Simpson Grading Scale continues to be widely accepted as the measure of EOR and is used to predict symptomatic recurrence, its utility is under increasing scrutiny. The influence of surgery in the definitive management of meningioma is being re-appraised considering the rapid evolution of our understanding of the biology of meningioma. DISCUSSION Although historically considered "benign" lesions, meningioma natural history can vary greatly, behaving with unexpectedly high recurrence rates and growth which do not always behave in accordance with their WHO grade. Histologically confirmed WHO grade 1 tumors may demonstrate unexpected recurrence, malignant transformation, and aggressive behavior, underscoring the molecular complexity and heterogeneity. CONCLUSION As our understanding of the clinical predictive power of genomic and epigenomic factors matures, we here discuss the importance of surgical decision-making paradigms in the context of our rapidly evolving understanding of these molecular features.
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Affiliation(s)
- Alper Dincer
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Saul F Morales-Valero
- Department of Neurosurgery, Yale School of Medicine, 15 York Street, LLCI 810, New Haven, CT, 06510, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Stephanie M Robert
- Department of Neurosurgery, Yale School of Medicine, 15 York Street, LLCI 810, New Haven, CT, 06510, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Joanna K Tabor
- Department of Neurosurgery, Yale School of Medicine, 15 York Street, LLCI 810, New Haven, CT, 06510, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Joseph O'Brien
- Department of Neurosurgery, Yale School of Medicine, 15 York Street, LLCI 810, New Haven, CT, 06510, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Kanat Yalcin
- Department of Neurosurgery, Yale School of Medicine, 15 York Street, LLCI 810, New Haven, CT, 06510, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Robert K Fulbright
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Zeynep Erson-Omay
- Department of Neurosurgery, Yale School of Medicine, 15 York Street, LLCI 810, New Haven, CT, 06510, USA
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA
| | - Ian F Dunn
- Department of Neurosurgery, Oklahoma University Medical Center, Oklahoma City, OK, USA
| | - Jennifer Moliterno
- Department of Neurosurgery, Yale School of Medicine, 15 York Street, LLCI 810, New Haven, CT, 06510, USA.
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, CT, USA.
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Hong CS, Marianayagam NJ, Morales-Valero SF, Barak T, Tabor JK, O’Brien J, Huttner A, Baehring J, Gunel M, Erson-Omay EZ, Fulbright RK, Matouk CC, Moliterno J. Vascular steal and associated intratumoral aneurysms in highly vascular brain tumors: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE22512. [PMID: 36880509 PMCID: PMC10550659 DOI: 10.3171/case22512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/30/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND Intratumoral aneurysms in highly vascular brain tumors can complicate resection depending on their location and feasibility of proximal control. Seemingly unrelated neurological symptoms may be from vascular steal that can help alert the need for additional vascular imaging and augmenting surgical strategies. OBSERVATIONS A 29-year-old female presented with headaches and unilateral blurred vision, secondary to a large right frontal dural-based lesion with hypointense signal thought to represent calcifications. Given these latter findings and clinical suspicion for a vascular steal phenomenon to explain the blurred vision, computed tomography angiography was obtained, revealing a 4 × 2-mm intratumoral aneurysm. Diagnostic cerebral angiography confirmed this along with vascular steal by the tumor from the right ophthalmic artery. The patient underwent endovascular embolization of the intratumoral aneurysm, followed by open tumor resection in the same setting without complication, minimal blood loss, and improvement in her vision. LESSONS Understanding the blood supply of any tumor, but highly vascular ones in particular, and the relationship with normal vasculature is undeniably important in avoiding potentially dangerous situations and optimizing maximal safe resection. Recognition of highly vascular tumors should prompt thorough understanding of the vascular supply and relationship of intracranial vasculature with consideration of endovascular adjuncts when appropriate.
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Tabor JK, Lei H, Morales-Valero SF, O’Brien J, Gopal PP, Erson-Omay EZ, Fulbright RK, Moliterno J. Epstein-Barr virus-associated primary intracranial leiomyosarcoma in an immunocompetent patient: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE22532. [PMID: 36692065 PMCID: PMC10550697 DOI: 10.3171/case22532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/27/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Primary intracranial leiomyosarcomas (PILMSs) are extremely rare tumors arising from smooth muscle connective tissue. PILMSs have been shown to be associated with Epstein-Barr virus (EBV). Thus far, EBV-associated PILMS has been exclusively described in immunocompromised patients. OBSERVATIONS A 40-year-old male presented with a 2-year history of left-sided headaches, nausea, and vomiting. Magnetic resonance imaging demonstrated a large, heterogeneously enhancing, lobulated, dura-based mass arising from the left middle cranial fossa with associated edema and mass effect. The patient underwent an uncomplicated resection of suspected meningioma; neuropathology revealed the exceedingly rare diagnosis of EBV-associated PILMS. Follow-up testing for human immunodeficiency virus (HIV) and other immunodeficiencies confirmed the patient's immunocompetent status. LESSONS Primary intracranial smooth muscle tumors are often misdiagnosed as meningiomas due to their similar appearance on imaging. PILMSs have a poor prognosis and gross total resection is the mainstay of treatment in the absence of clear recommendations for management. Prompt diagnosis and resection are important; therefore, these tumors should be included in the differential of dura-based tumors, especially among immunocompromised patients. Although EBV-associated PILMSs usually occur in immunocompromised individuals, their presence cannot be ruled out in immunocompetent patients.
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Affiliation(s)
- Joanna K. Tabor
- Departments of Neurosurgery
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut
| | - Haoyi Lei
- Departments of Neurosurgery
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut
| | - Saul F. Morales-Valero
- Departments of Neurosurgery
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut
| | - Joseph O’Brien
- Departments of Neurosurgery
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut
| | | | - E. Zeynep Erson-Omay
- Departments of Neurosurgery
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut
| | - Robert K. Fulbright
- Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; and
| | - Jennifer Moliterno
- Departments of Neurosurgery
- The Chenevert Family Brain Tumor Center, Smilow Cancer Hospital, New Haven, Connecticut
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9
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Shepard MJ, Snyder MH, Soldozy S, Ampie LL, Morales-Valero SF, Jane JA. Radiological and clinical outcomes of pituitary apoplexy: comparison of conservative management versus early surgical intervention. J Neurosurg 2021:1-9. [PMID: 33930863 DOI: 10.3171/2020.9.jns202899] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/25/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early surgical intervention for patients with pituitary apoplexy (PA) is thought to improve visual outcomes and decrease mortality. However, some patients may have good clinical outcomes without surgery. The authors sought to compare the radiological and clinical outcomes of patients with PA who were managed conservatively versus those who underwent early surgery. METHODS Patients with symptomatic PA were identified. Radiological, endocrinological, and ophthalmological data were reviewed. Patients with progressive visual deterioration or ophthalmoplegia were candidates for early surgery (within 7 days). Patients without visual symptoms or whose symptoms improved on high-dose steroids were treated conservatively. Log-rank and univariate analysis compared clinical and radiological outcomes between those receiving early surgery and those who underwent intended conservative management. RESULTS Sixty-four patients with PA were identified: 47 (73.4%) underwent intended conservative management, while 17 (26.6%) had early surgery. Patients receiving early surgery had increased rates of impaired visual acuity (VA; 64.7% vs 27.7%, p = 0.009); visual field (VF) deficits (64.7% vs 19.2%, p = 0.002); and cranial neuropathies (58.8% vs 29.8%, p < 0.05) at presentation. Tumor volumes were greater in the early surgical cohort (15.1 ± 14.8 cm3 vs 4.5 ± 10.3 cm3, p < 0.001). The median clinical and radiological follow-up visits were longer in the early surgical cohort (70.0 and 64.4 months vs 26.0 and 24.7 months, respectively; p < 0.001). Among those with VA/VF deficits, visual outcomes were similar between both groups (p > 0.9). The median time to VA improvement (2.0 vs 3.0 months, p = 0.9; HR 0.9, 95% CI 0.3-3.5) and the median time to VF improvement (2.0 vs 1.5 months; HR 0.8, 95% CI 0.3-2.6, p = 0.8) were similar across both cohorts. Cranial neuropathy improvement was more common in conservatively managed patients (HR 4.8, 95% CI 1.5-15.4, p < 0.01). Conservative management failed in 7 patients (14.9%) and required surgery. PA volumes spontaneously regressed in 95.0% of patients (38/40) with successful conservative management, with a 6-month regression rate of 66.2%. Twenty-seven patients (19 in the conservative and 8 in the early surgical cohorts) responded to a prospectively administered Visual Function Questionnaire-25 (VFQ-25). VFQ-25 scores were similar across both cohorts (conservative 95.5 ± 3.8, surgery 93.2 ± 5.1, p = 0.3). Younger age, female sex, and patients with VF deficits or chiasmal compression were more likely to experience unsuccessful conservative management. Surgical outcomes were similar for patients receiving early versus delayed surgery. CONCLUSIONS These data suggest that a majority of patients with PA can be successfully managed without surgical intervention assuming close neurosurgical, radiological, and ophthalmological follow-up is available.
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Affiliation(s)
- Matthew J Shepard
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia.,2Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas; and
| | - M Harrison Snyder
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Sauson Soldozy
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Leonel L Ampie
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia.,3Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Saul F Morales-Valero
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - John A Jane
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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10
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Morales-Valero SF, Serchi E, Zoli M, Mazzatenta D, Van Gompel JJ. Endoscopic endonasal approach for craniovertebral junction pathology: a review of the literature. Neurosurg Focus 2015; 38:E15. [PMID: 25828491 DOI: 10.3171/2015.1.focus14831] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The transoral approach is the gold standard for ventral decompression of the brainstem caused by craniovertebral junction (CVJ) pathology. This approach is often associated with significant morbidity, related to swallowing and respiratory complications. The endoscopic endonasal approach was introduced to reduce the rate of these complications. However, the exact role of this approach in the treatment of CVJ pathology is not well defined. METHODS A comprehensive literature search was performed to identify series of patients with pathology of the CVJ treated via the endoscopie endonasal approach. Data on patient characteristics, indications for treatment, complications, and outcome were obtained and analyzed. RESULTS Twelve studies involving 72 patients were included. The most common indications for treatment were rheumatoid pannus (38.9%) and basilar invagination (29.2%). Cerebrospinal fluid leak was found in 18% of cases intraoperatively and 4.2% of cases postoperatively. One case of meningitis complicated by sepsis and death represents the procedure-related mortality of 1.4%. Of the patients without preoperative swallowing impairment, 95% returned to oral feeding on the 3rd postoperative day. Ninety-three percent of patients experienced improvement in neurological symptoms after the procedure. CONCLUSIONS The endonasal endoscopie approach is effective for the treatment of neural compression caused by CVJ pathology. It offers advantages such as lower rates of postoperative dysphagia and respiratory complications when compared with the more traditional transoral approach. However, these 2 approaches should be seen as complementary rather than alternatives. Patient-related factors as well as the surgeon's expertise must be considered when making treatment decisions.
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11
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Morales-Valero SF, Brinjikji W, Wald JT, Lanzino G. Low frequency of delayed ischemic events on MRI after flow diversion for intracranial aneurysms. J Neurosurg Sci 2015; 61:459-463. [PMID: 26159552 DOI: 10.23736/s0390-5616.16.03401-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The rate of silent ischemia detected on Magnetic Resonance Imaging (MRI) in the long-term follow-up period following endovascular treatment of intracranial aneurysms with the Pipeline Embolization Device (PED) is not well established. The purpose of this study was to evaluate the occurrence rate of silent ischemia detected on MRI in patients undergoing treatment of intracranial aneurysms with PED receiving at least 6 months of MRI follow-up. METHODS We evaluated our institution's database of patients receiving PED treatment of intracranial aneurysms. Imaging records were searched to identify which patients received an MRI at least six-months postoperatively. MR images were reviewed for evidence of new infarction and medical records were reviewed to determine the clinical outcome. RESULTS Of the 68 patients with MR imaging following aneurysm treatment with PED, 40 patients had an MRI at least six months following treatment with the PED. Of patients with MRI at ≥6 months following PED treatment, 2/40 (5.0%) had a new infarct. Of these, one had a lacunar infarct which was likely non-embolic and one patient had a punctate infarction in the contralateral centrum semiovale. None of these infarcts were symptomatic. CONCLUSIONS In this study, a small number of silent ischemic events (5.0%) was found on routine long-term follow-up MRI of patients undergoing flow diversion. These events did not lead to any neurologic deficits. Our findings add to the available evidence on the long-term safety of flow diversion for the treatment of intracranial aneurysms.
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Affiliation(s)
| | | | - John T Wald
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Radiology, Mayo Clinic, Rochester, MN, USA
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12
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Abstract
Intramedullary ependymomas are surgically curable tumors. However, their surgical resection poses several challenges. In this intraoperative video we illustrate the main steps for the surgical resection of a cervical intramedullary ependymoma. These critical steps include: adequate exposure of the entire length of the tumor; use of the intraoperative ultrasound; identification of the posterior median sulcus and separation of the posterior columns; Identification of the plane between the spinal cord and the tumor; mobilization and debulking of the tumor and disconnection of the vascular supply (usually from small anterior spinal artery branches). Following these basic steps a complete resection can be safely achieved in many cases. The video can be found here: http://youtu.be/QMYXC_F4O4U.
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Affiliation(s)
- Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota
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13
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Abstract
The surgical treatment of meningiomas located at the base of the anterior cranial fossa is often challenging, and the evolution of the surgical strategy to resect these tumors parallels the development of craniotomy, and neurosurgery in general, over the past century. Early successful operations to treat these tumors were pioneered by prominent figures such as Sir William Macewen and Francesco Durante. Following these early reports, Harvey Cushing made significant contributions, allowing a better understanding and treatment of meningiomas in general, but particularly those involving the anterior cranial base. Initially, large-sized unilateral or bilateral craniotomies were necessary to approach these deep-seated lesions. Technical advances such as the introduction of electrosurgery, the operating microscope, and refined microsurgical instruments allowed neurosurgeons to perform less invasive surgical procedures with better results. Today, a wide variety of surgical strategies, including endoscopic surgery and radiosurgery, are used to treat these tumors. In this review, the authors trace the evolution of craniotomy for anterior cranial fossa meningiomas.
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Affiliation(s)
- Saul F Morales-Valero
- Department of Neurologic Surgery, Mayo Clinic, Mayo Medical School, Rochester, Minnesota
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14
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Ronchetti G, Morales-Valero SF, Lanzino G, Wald JT. A Cause of Atypical Intracranial Subarachnoid Hemorrhage: Posterior Spinal Artery Aneurysms. Neurocrit Care 2014; 22:299-305. [DOI: 10.1007/s12028-014-0009-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Lanzino G, Morales-Valero SF, Krauss WE. Resection of spinal hemangioblastoma. Neurosurg Focus 2014; 37 Suppl 2:Video 15. [PMID: 25175576 DOI: 10.3171/2014.v3.focus14379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal cord hemangioblastomas occur as sporadic lesions or in the setting of Von Hippel-Lindau disease. In this intraoperative video we present a case of sporadic cervical cord hemangioblastoma and illustrate the main surgical steps to achieve safe and complete resection which include: identification and division of the feeding arteries; careful circumferential dissection of the tumor from the surrounding gliotic cord; identification, isolation and division of the main venous drainage and single piece removal of the tumor. The video can be found here: http://youtu.be/I7DxqRrfTxc.
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Affiliation(s)
- Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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16
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Abstract
A long-held dogma in neurosurgery is that parenchymal arteriovenous malformations (AVMs) are congenital. However, there is no strong evidence supporting this theory. An increasing number of documented cases of de novo formation of parenchymal AVMs cast doubt on their congenital nature and suggest that indeed the majority of these lesions may form after birth. Further evidence suggesting the postnatal development of parenchymal AVMs comes from the exceedingly rare diagnosis of these lesions in utero despite the widespread availability of high-resolution imaging modalities such as ultrasound and fetal MRI. The exact mechanism of AVM formation has yet to be elucidated, but most likely involves genetic susceptibility and environmental triggering factors. In this review, the authors report 2 cases of de novo AVM formation and analyze the evidence suggesting that they represent an acquired condition.
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Affiliation(s)
- Saul F. Morales-Valero
- 1Department of Neurologic Surgery, Mayo Clinic, Mayo Medical School, Rochester, Minnesota; and
| | - Carlo Bortolotti
- 2Department of Neurosurgery, IRCCS Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - Carmelo Sturiale
- 2Department of Neurosurgery, IRCCS Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - Giuseppe Lanzino
- 1Department of Neurologic Surgery, Mayo Clinic, Mayo Medical School, Rochester, Minnesota; and
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Brinjikji W, Morales-Valero SF, Murad MH, Cloft HJ, Kallmes DF. Rescue treatment of thromboembolic complications during endovascular treatment of cerebral aneurysms: a meta-analysis. AJNR Am J Neuroradiol 2014; 36:121-5. [PMID: 25082819 DOI: 10.3174/ajnr.a4066] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intraprocedural thrombus formation during endovascular treatment of intracranial aneurysms is often treated with glycoprotein IIb/IIIa inhibitors and, in some instances, fibrinolytic therapy. We performed a meta-analysis evaluating the safety and efficacy of GP IIb/IIIa inhibitors compared with fibrinolysis. We also evaluated the safety and efficacy of abciximab, an irreversible inhibitor, compared with tirofiban and eptifibatide, reversible inhibitors of platelet function. MATERIALS AND METHODS We performed a comprehensive literature search for studies on rescue therapy for intraprocedural thromboembolic complications with glycoprotein IIb/IIIa inhibitors or fibrinolysis during endovascular treatment of intracranial aneurysms. We studied rates of periprocedural stroke/hemorrhage, procedure-related morbidity and mortality, immediate arterial recanalization, and long-term good clinical outcome. Event rates were pooled across studies by using random-effects meta-analysis. RESULTS Twenty-three studies with 516 patients were included. Patients receiving GP IIb/IIIa inhibitors had significantly lower perioperative morbidity from stroke/hemorrhage compared with those treated with fibrinolytics (11.0%; 95% CI, 7.0%-16.0% versus 29.0%; 95% CI, 13.0%-55.0%; P = .04) and were significantly less likely to have long-term morbidity (16.0%; 95% CI, 11.0%-21.0% versus 35.0%; 95% CI, 17.0%-58.0%; P = .04). There was a trend toward higher recanalization rates among patients treated with glycoprotein IIb/IIIa inhibitors compared with those treated with fibrinolytics (72.0%; 95% CI, 64.0%-78.0% versus 50.0%; 95% CI, 28.0%-73.0%; P = .08). Patients receiving tirofiban or eptifibatide had significantly higher recanalization rates compared with those treated with abciximab (83.0%; 95% CI, 68.0%-91.0% versus 66.0%; 95% CI, 58.0%-74.0%; P = .05). No difference in recanalization was seen in patients receiving intra-arterial (77.0%; 95% CI, 66.0%-85.0%) or intravenous GP IIb/IIIa inhibitors (70.0%; 95% CI, 57.0%-80.0%, P = .36). CONCLUSIONS Rescue therapy with thrombolytic agents resulted in significantly more morbidity than rescue therapy with glycoprotein IIb/IIIa inhibitors. Tirofiban/eptifibatide resulted in significantly higher recanalization rates compared with abciximab.
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Affiliation(s)
- W Brinjikji
- From the Departments of Radiology (W.B., H.J.C., D.F.K.)
| | | | - M H Murad
- Center for Science of Healthcare Delivery (M.H.M.), Mayo Clinic, Rochester, Minnesota
| | - H J Cloft
- From the Departments of Radiology (W.B., H.J.C., D.F.K.) Neurosurgery (S.F.M.-V., H.J.C., D.F.K.)
| | - D F Kallmes
- From the Departments of Radiology (W.B., H.J.C., D.F.K.) Neurosurgery (S.F.M.-V., H.J.C., D.F.K.)
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18
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Morales-Valero SF, Brinjikji W, Murad MH, Wald JT, Lanzino G. Endovascular treatment of internal carotid artery bifurcation aneurysms: a single-center experience and a systematic review and meta-analysis. AJNR Am J Neuroradiol 2014; 35:1948-53. [PMID: 24904050 DOI: 10.3174/ajnr.a3992] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular coiling of internal carotid artery bifurcation aneurysms can be challenging due to unfavorable morphologic features. With improvements in endovascular techniques, several series have detailed the results and complications of endovascular treatment of aneurysms at this location. We performed a systematic review and meta-analysis of published series on the endovascular treatment of ICA bifurcation aneurysms, including a tertiary referral center experience. MATERIALS AND METHODS We performed a comprehensive literature search for reports on contemporary endovascular treatment of ICA bifurcation aneurysms from 2000 to 2013, and we reviewed our experience. We extracted information regarding periprocedural complications, procedure-related morbidity and mortality, immediate angiographic outcome, long-term clinical and angiographic outcome, and retreatment rate. Event rates were pooled across studies by using random-effects meta-analysis. RESULTS Including our series of 37 patients, 6 studies with 158 patients were analyzed. Approximately 60% of the aneurysms presented as unruptured; 88.0% (95% CI, 68.0%-96.0%) of aneurysms showed complete or near-complete occlusion at immediate postoperative angiography compared with 82.0% (95% CI, 73.0%-88.0%) at last follow-up. The procedure-related morbidity and mortality were 3.0% (95% CI, 1.0%-7.0%) and 3.0% (95% CI, 1.0%-8.0%), respectively. The retreatment rate was 14.0% (95% CI, 8.0%-25.0%). Good neurologic outcome was achieved in 93.0% (95% CI, 86.0%-97.0%) of patients. CONCLUSIONS Endovascular treatment of ICA bifurcation aneurysms is feasible and effective and is associated with high immediate angiographic occlusion rates. However, retreatment rates and procedure-related morbidity and mortality are non-negligible.
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Affiliation(s)
| | | | - M H Murad
- Center for Science of Healthcare Delivery (M.H.M.), Mayo Clinic, Rochester, Minnesota
| | | | - G Lanzino
- From the Departments of Neurologic Surgery (S.F.M.-V., G.L.) Radiology (W.B., J.T.W., G.L.)
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19
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Abstract
Asymptomatic carotid artery stenosis is a well-recognized risk factor for ischemic stroke, and its prevalence increases with age. In the late 1980s and in the 1990s, well-designed randomized trials established a definite advantage for carotid endarterectomy in reducing the risk of ipsilateral stroke when compared with medical therapy alone. However, medical treatment of cardiovascular disease has improved significantly over the past 2 decades, and this has, in turn, resulted in a decline of the stroke risk in patients with asymptomatic carotid artery stenosis treated medically. This improvement in medical therapy casts doubts on the effectiveness of large-scale invasive treatment in patients with asymptomatic carotid artery stenosis. Several studies have been conducted to identify possible subgroups of patients with asymptomatic stenosis who are at higher risk of stroke in order to maximize the potential benefits of invasive treatment. Ongoing large-scale trials comparing best current medical therapy to available invasive treatments, such as carotid endarterectomy and carotid artery stenting, are likely to shed some light on this debated topic in the near future. In this review, the authors summarize the current controversy surrounding the ideal management of asymptomatic carotid artery stenosis.
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