Background The authors explored the relationship between nitrous oxide use and neurologic and neu... more Background The authors explored the relationship between nitrous oxide use and neurologic and neuropsychological outcome in a population of patients likely to experience intraoperative cerebral ischemia: those who had temporary cerebral arterial occlusion during aneurysm clipping surgery. Methods A post hoc analysis of a subset of the data from the Intraoperative Hypothermia for Aneurysm Surgery Trial was conducted. Only subjects who had temporary arterial occlusion during surgery were included in the analysis. Metrics of short-term and long-term (i.e., 3 months after surgery) outcome were evaluated via both univariate and multivariate logistic regression analysis. An odds ratio (OR) greater than 1.0 denotes a worse outcome in patients receiving nitrous oxide. Results The authors evaluated 441 patients, of which 199 received nitrous oxide. Patients receiving nitrous oxide had a greater risk of delayed ischemic neurologic deficits (i.e., the clinical manifestation of vasospasm) (OR, ...
Purpose: Neuronavigation based on preoperative imaging data is a ubiquitous tool for image guidan... more Purpose: Neuronavigation based on preoperative imaging data is a ubiquitous tool for image guidance in neurosurgery. However, it is rendered unreliable when brain shift invalidates the patient‐to‐image registration. Many investigators have tried to explain, quantify, and compensate for this phenomenon to allow extended use of neuronavigation systems for the duration of surgery. The purpose of this paper is to present an overview of the work that has been done investigating brain shift. Methods: A review of the literature dealing with the explanation, quantification and compensation of brain shift is presented. The review is based on a systematic search using relevant keywords and phrases in PubMed. The review is organized based on a developed taxonomy that classifies brain shift as occurring due to physical, surgical or biological factors. Results: This paper gives an overview of the work investigating, quantifying, and compensating for brain shift in neuronavigation while describing the successes, setbacks, and additional needs in the field. An analysis of the literature demonstrates a high variability in the methods used to quantify brain shift as well as a wide range in the measured magnitude of the brain shift, depending on the specifics of the intervention. The analysis indicates the need for additional research to be done in quantifying independent effects of brain shift in order for some of the state of the art compensation methods to become useful. Conclusion: This review allows for a thorough understanding of the work investigating brain shift and introduces the needs for future avenues of investigation of the phenomenon. HighlightsA comprehensive review of research on the phenomenon of brain shift.A new taxonomy separating brain shift into physical, biological and surgical factors.Contrast between brain shift corrections through intraoperative imaging methods.Recommendations for future focus of brain shift research. Graphical abstract Figure. Image, graphical abstract
glucose levels & HbA1c in the stressed were significantly higher compared to control (p<0.001). S... more glucose levels & HbA1c in the stressed were significantly higher compared to control (p<0.001). Serum lipids were found insignificantly higher in stressed mice compared to control. Body weights of the stressed mice and feed efficiency ratio were found significant (p<0.001). Plasma corticosterone, plasma epinephrine, HOMA-IR was found to be significantly higher in the stressed group (p<0.001). Plasma insulin level was found to be significantly lower in the stressed group (p< 0.001). Significant changes were observed in antioxidants level, carbohydrate metabolizing enzymes activity, peripheral tissues and DNA integrity. Expression of IL-4, IL-6 was found significantly higher in the stressed group. Conclusions: CUES initiates pathogenesis of diabetes.
Objective To determine the volumetric growth in macroadenomas (MAs) patients with residual postop... more Objective To determine the volumetric growth in macroadenomas (MAs) patients with residual postoperative disease and to identify subpopulations with rapid postoperative growth rate that may benefit from early salvage radiotherapy (RT). Methods Patients who had undergone a partial resection for MAs and did not receive immediate postoperative RT were eligible. Residual tissue was contoured on serial magnetic resonance imaging and planimetric and volumetric changes in size were measured. Growth rates were established by a single observer using serial volumetric measurements. Data were analyzed to find a relationship among growth rate, adjuvant treatment, and patient and tumor characteristics. Results Thirty-one patients met the eligibility criteria. Nine patients (29%) required adjuvant treatment because of tumor growth. Volumetric growth was identified 95% of the time compared with 64% planimetrically. Planimetric growth could not be established in 10% of patients showing volumetric changes. Median growth rate was 0.4464 mL/y. Growth rate positively correlated with size of residual postoperative volume (p < 0.001). Receiving salvage treatment positively correlated with growth rate (p ¼ 0.001), particularly at a rate above 2.19 mL/y (p ¼ 0.0064). Five patients (16%) had a growth rate above this level, all of which required salvage treatment. Patients with postoperative residual volume > 3.95 mL were most likely to experience rapid growth rate and require salvage treatment (p ¼ 0.007). Conclusion Volumetric measurement was found to be superior to planimetric measurement in detecting changes in patients with residual tumors. Patients with postoperative residual volume > 3.95 mL should be considered for early treatment with RT.
We report an unusual case of a ruptured aneurysm from an infraoptic anterior cerebral artery in a... more We report an unusual case of a ruptured aneurysm from an infraoptic anterior cerebral artery in an 11-year-old child. To our knowledge, this is the second such case treated with Guglielmi detachable coils in the pediatric population that has been described in the literature, excluding that of a vein of Galen aneurysm that resulted in remarkable recovery. We conclude that the endovascular technique is a feasible treatment option for children with ruptured cerebral aneurysms, especially when more complex vascular anomalies are present.
Neuronavigation using pre-operative imaging data for neurosurgical guidance is a ubiquitous tool ... more Neuronavigation using pre-operative imaging data for neurosurgical guidance is a ubiquitous tool for the planning and resection of oncologic brain disease. These systems are rendered unreliable when brain shift invalidates the patient-image registration. Our previous review in 2015, Brain shift in neuronavigation of brain tumours: A review offered a new taxonomy, classification system, and a historical perspective on the causes, measurement, and pre-and intra-operative compensation of this phenomenon. Here we present an updated review using the same taxonomy and framework, focused on the developments of intra-operative ultrasound-based brain shift research from 2015 to the present (2020). The review was performed using PubMed to identify articles since 2015 with the specific words and phrases: "Brain shift" AND "Ultrasound". Since 2015, the rate of publication of intra-operative ultrasound based articles in the context of brain shift has increased from 2-3 per year to 8-10 per year. This efficient and low-cost technology and increasing comfort among clinicians and researchers have allowed unique avenues of development. Since 2015, there has been a trend towards more mathematical advancements in the field which is often validated on publicly available datasets from early intra-operative ultrasound research, and may not give a just representation to the intra-operative imaging landscape in modern imageguided neurosurgery. Focus on vessel-based registration and virtual and augmented reality paradigms have seen traction, offering new perspectives to overcome some of the different pitfalls of ultrasound based technologies. Unfortunately, clinical adaptation and evaluation has not seen as significant of a publication boost. Brain shift continues to be a highly prevalent pitfall in maintaining accuracy throughout oncologic neurosurgical intervention and continues to be an area of active research. Intra-operative ultrasound continues to show promise as an effective, efficient, and low-cost solution for intraoperative accuracy management. A major drawback of the current research landscape is that mathematical tool validation based on retrospective data outpaces prospective clinical evaluations decreasing the strength of the evidence. The need for newer and
International Journal of Radiation Oncology Biology Physics, Sep 1, 2014
7 patients (5%) experienced DF. On univariate analysis, only GTR was predictive of LF (HR Z 0.55,... more 7 patients (5%) experienced DF. On univariate analysis, only GTR was predictive of LF (HR Z 0.55, p Z 0.028). Extent of resection was not predictive of OS (HR Z 0.53, p Z 0.10). Among all patients, adjuvant radiation therapy did not improve LF (HR Z 0.79, p Z 0.53). Among patients with Simpson grade 4 or 5 resection, adjuvant RT significantly reduced LF (HR Z 0.38, p Z 0.036). Median time to LF in this subset was significantly prolonged by adjuvant RT (25 to 63 months). Adjuvant RT was not associated with time to local failure in patients who underwent GTR. Conclusions: Adjuvant RT improves time to local failure in patients with atypical meningiomas who undergo upfront Simpson grade 4 or 5 resection but not in patients who undergo upfront GTR.
The coexistence of brain tumours and aneurysms is rare. In all previously reported cases the aneu... more The coexistence of brain tumours and aneurysms is rare. In all previously reported cases the aneurysm was detectable by angiography. We report here a case in which a paraclinoid internal carotid artery aneurysm was coexistent and concealed from angiographic detection by an adjacent parasellar meningioma.
International Journal of Computer Assisted Radiology and Surgery, Aug 31, 2016
Purpose Navigation systems commonly used in neurosurgery suffer from two main drawbacks: (1) thei... more Purpose Navigation systems commonly used in neurosurgery suffer from two main drawbacks: (1) their accuracy degrades over the course of the operation and (2) they require the surgeon to mentally map images from the monitor to the patient. In this paper, we introduce the Intraoperative Brain Imaging System (IBIS), an open-source image-guided neurosurgery research platform that implements a novel workflow where navigation accuracy is improved using tracked intraoperative ultrasound (iUS) and the visualization of navigation information is facilitated through the use of augmented reality (AR). Methods The IBIS platform allows a surgeon to capture tracked iUS images and use them to automatically update preoperative patient models and plans through fast GPUbased reconstruction and registration methods. Navigation, resection and iUS-based brain shift correction can all be performed using an AR view. IBIS has an intuitive graphical user interface for the calibration of a US probe, a surgical pointer as well as video devices used for AR (e.g., a surgical microscope). Results The components of IBIS have been validated in the laboratory and evaluated in the operating room. Image-topatient registration accuracy is on the order of 3.72±1.27 mm and can be improved with iUS to a median target registration error of 2.54 mm. The accuracy of the US probe calibration is between 0.49 and 0.82 mm. The average reprojection error of the AR system is 0.37 ± 0.19 mm. The system has been used in the operating room for various types of surgery, including
Background Large vestibular schwannomas (VSs) can cause hydrocephalus by obstructing the fourth v... more Background Large vestibular schwannomas (VSs) can cause hydrocephalus by obstructing the fourth ventricle. Little is known about the communicating hydrocephalus that is seen with a smaller VS. Methods The clinicopathological findings and follow up of three patients with communicating hydrocephalus associated with a small VS are presented. Results Four patients aged 40 to 66 years (mean: 57.7) presented with ataxia, dementia, and urinary incontinence. The VS were 2.0 to 2.4 cm. The cerebrospinal fluid (CSF) protein was elevated in three patients in whom it was measured (1.7 to 6 times normal). The VS was resected in two patients. All of the patients required ventriculoperitoneal shunting (VPS). All of the patients were asymptomatic or improved at follow-up at 9 months to 13 years. Conclusion Communicating hydrocephalus associated with a VS can occur in younger patients than was previously thought. An elevated CSF protein appears to be important, but other factors may be involved. A shunting procedure is often required to relieve the symptoms of hydrocephalus even if the tumor is resected. Possible etiological causes of communicating hydrocephalus in patients with a small VS are discussed.
The objective of this study was to identify clinico-radiologic factors associated with incomplete... more The objective of this study was to identify clinico-radiologic factors associated with incomplete anterior cranial fossa (ACF) meningioma resection via an endoscopic endonasal approach. Methods Patients undergoing endoscopic endonasal resection of an ACF meningioma were retrospectively accrued from two university-affiliated centers. Demographic profiles and radiologic findings, including tumor dimensions and morphology, anatomic location and vascular involvement were stratified based on the extent of resection. Results In total, 25 patients were included in this study. Factors associated with incomplete surgical resection via an endonasal route were: presence of hyperostosis (p=0.04), cavernous internal carotid artery (ICA) involvement (p=0.001), maximal dural tail length in the transverse plane (p=0.006) and its ratio to the inter-fovea ethmoidalis distance (p=0.01). Using a multiple regression analysis, only cavernous ICA involvement (p=0.002) and a large dural tail length to inter-foveal distance ratio (p=0.04) were significant predictors of incomplete resection (multiple correlation coefficient 0.71). The combination of predictive factors to determine the likelihood of complete endoscopic resection produced a scoring system with a sensitivity and specificity of 85.7% CI [42.1-99.6] and 100% CI [81.5-100], respectively. Conclusion Use of a simple scoring system outlined in our study may facilitate proper patient selection for endoscopic endonasal resection of ACF meningiomas.
Objective The continually evolving coronavirus disease 2019 (COVID-19) pandemic has created a di... more Objective The continually evolving coronavirus disease 2019 (COVID-19) pandemic has created a dire need for rapid reorganization of health care delivery within surgical services. Ensuing initial reports of high infection rates following endoscopic sinus and skull base surgery, various expert and societal guidelines have emerged. We hereby provide a scoping review of the available literature on endoscopic sinus and skull base surgery, exploring both the risk of aerosolization and expert recommendations on surgical management during the pandemic. Methods A literature search of the PubMed database was performed up until May 9th, 2020. Additionally, websites and published statements from otolaryngology associations were searched for recommendations. This scoping review followed the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews. Results A total of 29 peer-reviewed publications and statements from expert recommendations or professional associations were included. Current expert guidance relies mainly on scarce, anecdotal evidence, and two cadaveric studies, which have demonstrated potential aerosolization during transnasal surgery. General consensus exists for delaying surgery when possible, ascertaining COVID-19 status preoperatively and donning of adequate personal protective equipment by all operating room staff (including at minimum an N95 mask). Cold, nonpowered surgical instruments are deemed the safest, while thermal instruments (electrocautery and laser) and high-speed drills should be minimized. Conflicting recommendations emerge for use of microdebriders. Conclusion Endoscopic sinus and skull base surgery impart a potential risk of aerosolization. Hence, surgical indications, protective measures for health care workers, and surgical instrumentation must be adapted accordingly in the COVID-19 context.
Background The authors explored the relationship between nitrous oxide use and neurologic and neu... more Background The authors explored the relationship between nitrous oxide use and neurologic and neuropsychological outcome in a population of patients likely to experience intraoperative cerebral ischemia: those who had temporary cerebral arterial occlusion during aneurysm clipping surgery. Methods A post hoc analysis of a subset of the data from the Intraoperative Hypothermia for Aneurysm Surgery Trial was conducted. Only subjects who had temporary arterial occlusion during surgery were included in the analysis. Metrics of short-term and long-term (i.e., 3 months after surgery) outcome were evaluated via both univariate and multivariate logistic regression analysis. An odds ratio (OR) greater than 1.0 denotes a worse outcome in patients receiving nitrous oxide. Results The authors evaluated 441 patients, of which 199 received nitrous oxide. Patients receiving nitrous oxide had a greater risk of delayed ischemic neurologic deficits (i.e., the clinical manifestation of vasospasm) (OR, ...
Purpose: Neuronavigation based on preoperative imaging data is a ubiquitous tool for image guidan... more Purpose: Neuronavigation based on preoperative imaging data is a ubiquitous tool for image guidance in neurosurgery. However, it is rendered unreliable when brain shift invalidates the patient‐to‐image registration. Many investigators have tried to explain, quantify, and compensate for this phenomenon to allow extended use of neuronavigation systems for the duration of surgery. The purpose of this paper is to present an overview of the work that has been done investigating brain shift. Methods: A review of the literature dealing with the explanation, quantification and compensation of brain shift is presented. The review is based on a systematic search using relevant keywords and phrases in PubMed. The review is organized based on a developed taxonomy that classifies brain shift as occurring due to physical, surgical or biological factors. Results: This paper gives an overview of the work investigating, quantifying, and compensating for brain shift in neuronavigation while describing the successes, setbacks, and additional needs in the field. An analysis of the literature demonstrates a high variability in the methods used to quantify brain shift as well as a wide range in the measured magnitude of the brain shift, depending on the specifics of the intervention. The analysis indicates the need for additional research to be done in quantifying independent effects of brain shift in order for some of the state of the art compensation methods to become useful. Conclusion: This review allows for a thorough understanding of the work investigating brain shift and introduces the needs for future avenues of investigation of the phenomenon. HighlightsA comprehensive review of research on the phenomenon of brain shift.A new taxonomy separating brain shift into physical, biological and surgical factors.Contrast between brain shift corrections through intraoperative imaging methods.Recommendations for future focus of brain shift research. Graphical abstract Figure. Image, graphical abstract
glucose levels & HbA1c in the stressed were significantly higher compared to control (p<0.001). S... more glucose levels & HbA1c in the stressed were significantly higher compared to control (p<0.001). Serum lipids were found insignificantly higher in stressed mice compared to control. Body weights of the stressed mice and feed efficiency ratio were found significant (p<0.001). Plasma corticosterone, plasma epinephrine, HOMA-IR was found to be significantly higher in the stressed group (p<0.001). Plasma insulin level was found to be significantly lower in the stressed group (p< 0.001). Significant changes were observed in antioxidants level, carbohydrate metabolizing enzymes activity, peripheral tissues and DNA integrity. Expression of IL-4, IL-6 was found significantly higher in the stressed group. Conclusions: CUES initiates pathogenesis of diabetes.
Objective To determine the volumetric growth in macroadenomas (MAs) patients with residual postop... more Objective To determine the volumetric growth in macroadenomas (MAs) patients with residual postoperative disease and to identify subpopulations with rapid postoperative growth rate that may benefit from early salvage radiotherapy (RT). Methods Patients who had undergone a partial resection for MAs and did not receive immediate postoperative RT were eligible. Residual tissue was contoured on serial magnetic resonance imaging and planimetric and volumetric changes in size were measured. Growth rates were established by a single observer using serial volumetric measurements. Data were analyzed to find a relationship among growth rate, adjuvant treatment, and patient and tumor characteristics. Results Thirty-one patients met the eligibility criteria. Nine patients (29%) required adjuvant treatment because of tumor growth. Volumetric growth was identified 95% of the time compared with 64% planimetrically. Planimetric growth could not be established in 10% of patients showing volumetric changes. Median growth rate was 0.4464 mL/y. Growth rate positively correlated with size of residual postoperative volume (p < 0.001). Receiving salvage treatment positively correlated with growth rate (p ¼ 0.001), particularly at a rate above 2.19 mL/y (p ¼ 0.0064). Five patients (16%) had a growth rate above this level, all of which required salvage treatment. Patients with postoperative residual volume > 3.95 mL were most likely to experience rapid growth rate and require salvage treatment (p ¼ 0.007). Conclusion Volumetric measurement was found to be superior to planimetric measurement in detecting changes in patients with residual tumors. Patients with postoperative residual volume > 3.95 mL should be considered for early treatment with RT.
We report an unusual case of a ruptured aneurysm from an infraoptic anterior cerebral artery in a... more We report an unusual case of a ruptured aneurysm from an infraoptic anterior cerebral artery in an 11-year-old child. To our knowledge, this is the second such case treated with Guglielmi detachable coils in the pediatric population that has been described in the literature, excluding that of a vein of Galen aneurysm that resulted in remarkable recovery. We conclude that the endovascular technique is a feasible treatment option for children with ruptured cerebral aneurysms, especially when more complex vascular anomalies are present.
Neuronavigation using pre-operative imaging data for neurosurgical guidance is a ubiquitous tool ... more Neuronavigation using pre-operative imaging data for neurosurgical guidance is a ubiquitous tool for the planning and resection of oncologic brain disease. These systems are rendered unreliable when brain shift invalidates the patient-image registration. Our previous review in 2015, Brain shift in neuronavigation of brain tumours: A review offered a new taxonomy, classification system, and a historical perspective on the causes, measurement, and pre-and intra-operative compensation of this phenomenon. Here we present an updated review using the same taxonomy and framework, focused on the developments of intra-operative ultrasound-based brain shift research from 2015 to the present (2020). The review was performed using PubMed to identify articles since 2015 with the specific words and phrases: "Brain shift" AND "Ultrasound". Since 2015, the rate of publication of intra-operative ultrasound based articles in the context of brain shift has increased from 2-3 per year to 8-10 per year. This efficient and low-cost technology and increasing comfort among clinicians and researchers have allowed unique avenues of development. Since 2015, there has been a trend towards more mathematical advancements in the field which is often validated on publicly available datasets from early intra-operative ultrasound research, and may not give a just representation to the intra-operative imaging landscape in modern imageguided neurosurgery. Focus on vessel-based registration and virtual and augmented reality paradigms have seen traction, offering new perspectives to overcome some of the different pitfalls of ultrasound based technologies. Unfortunately, clinical adaptation and evaluation has not seen as significant of a publication boost. Brain shift continues to be a highly prevalent pitfall in maintaining accuracy throughout oncologic neurosurgical intervention and continues to be an area of active research. Intra-operative ultrasound continues to show promise as an effective, efficient, and low-cost solution for intraoperative accuracy management. A major drawback of the current research landscape is that mathematical tool validation based on retrospective data outpaces prospective clinical evaluations decreasing the strength of the evidence. The need for newer and
International Journal of Radiation Oncology Biology Physics, Sep 1, 2014
7 patients (5%) experienced DF. On univariate analysis, only GTR was predictive of LF (HR Z 0.55,... more 7 patients (5%) experienced DF. On univariate analysis, only GTR was predictive of LF (HR Z 0.55, p Z 0.028). Extent of resection was not predictive of OS (HR Z 0.53, p Z 0.10). Among all patients, adjuvant radiation therapy did not improve LF (HR Z 0.79, p Z 0.53). Among patients with Simpson grade 4 or 5 resection, adjuvant RT significantly reduced LF (HR Z 0.38, p Z 0.036). Median time to LF in this subset was significantly prolonged by adjuvant RT (25 to 63 months). Adjuvant RT was not associated with time to local failure in patients who underwent GTR. Conclusions: Adjuvant RT improves time to local failure in patients with atypical meningiomas who undergo upfront Simpson grade 4 or 5 resection but not in patients who undergo upfront GTR.
The coexistence of brain tumours and aneurysms is rare. In all previously reported cases the aneu... more The coexistence of brain tumours and aneurysms is rare. In all previously reported cases the aneurysm was detectable by angiography. We report here a case in which a paraclinoid internal carotid artery aneurysm was coexistent and concealed from angiographic detection by an adjacent parasellar meningioma.
International Journal of Computer Assisted Radiology and Surgery, Aug 31, 2016
Purpose Navigation systems commonly used in neurosurgery suffer from two main drawbacks: (1) thei... more Purpose Navigation systems commonly used in neurosurgery suffer from two main drawbacks: (1) their accuracy degrades over the course of the operation and (2) they require the surgeon to mentally map images from the monitor to the patient. In this paper, we introduce the Intraoperative Brain Imaging System (IBIS), an open-source image-guided neurosurgery research platform that implements a novel workflow where navigation accuracy is improved using tracked intraoperative ultrasound (iUS) and the visualization of navigation information is facilitated through the use of augmented reality (AR). Methods The IBIS platform allows a surgeon to capture tracked iUS images and use them to automatically update preoperative patient models and plans through fast GPUbased reconstruction and registration methods. Navigation, resection and iUS-based brain shift correction can all be performed using an AR view. IBIS has an intuitive graphical user interface for the calibration of a US probe, a surgical pointer as well as video devices used for AR (e.g., a surgical microscope). Results The components of IBIS have been validated in the laboratory and evaluated in the operating room. Image-topatient registration accuracy is on the order of 3.72±1.27 mm and can be improved with iUS to a median target registration error of 2.54 mm. The accuracy of the US probe calibration is between 0.49 and 0.82 mm. The average reprojection error of the AR system is 0.37 ± 0.19 mm. The system has been used in the operating room for various types of surgery, including
Background Large vestibular schwannomas (VSs) can cause hydrocephalus by obstructing the fourth v... more Background Large vestibular schwannomas (VSs) can cause hydrocephalus by obstructing the fourth ventricle. Little is known about the communicating hydrocephalus that is seen with a smaller VS. Methods The clinicopathological findings and follow up of three patients with communicating hydrocephalus associated with a small VS are presented. Results Four patients aged 40 to 66 years (mean: 57.7) presented with ataxia, dementia, and urinary incontinence. The VS were 2.0 to 2.4 cm. The cerebrospinal fluid (CSF) protein was elevated in three patients in whom it was measured (1.7 to 6 times normal). The VS was resected in two patients. All of the patients required ventriculoperitoneal shunting (VPS). All of the patients were asymptomatic or improved at follow-up at 9 months to 13 years. Conclusion Communicating hydrocephalus associated with a VS can occur in younger patients than was previously thought. An elevated CSF protein appears to be important, but other factors may be involved. A shunting procedure is often required to relieve the symptoms of hydrocephalus even if the tumor is resected. Possible etiological causes of communicating hydrocephalus in patients with a small VS are discussed.
The objective of this study was to identify clinico-radiologic factors associated with incomplete... more The objective of this study was to identify clinico-radiologic factors associated with incomplete anterior cranial fossa (ACF) meningioma resection via an endoscopic endonasal approach. Methods Patients undergoing endoscopic endonasal resection of an ACF meningioma were retrospectively accrued from two university-affiliated centers. Demographic profiles and radiologic findings, including tumor dimensions and morphology, anatomic location and vascular involvement were stratified based on the extent of resection. Results In total, 25 patients were included in this study. Factors associated with incomplete surgical resection via an endonasal route were: presence of hyperostosis (p=0.04), cavernous internal carotid artery (ICA) involvement (p=0.001), maximal dural tail length in the transverse plane (p=0.006) and its ratio to the inter-fovea ethmoidalis distance (p=0.01). Using a multiple regression analysis, only cavernous ICA involvement (p=0.002) and a large dural tail length to inter-foveal distance ratio (p=0.04) were significant predictors of incomplete resection (multiple correlation coefficient 0.71). The combination of predictive factors to determine the likelihood of complete endoscopic resection produced a scoring system with a sensitivity and specificity of 85.7% CI [42.1-99.6] and 100% CI [81.5-100], respectively. Conclusion Use of a simple scoring system outlined in our study may facilitate proper patient selection for endoscopic endonasal resection of ACF meningiomas.
Objective The continually evolving coronavirus disease 2019 (COVID-19) pandemic has created a di... more Objective The continually evolving coronavirus disease 2019 (COVID-19) pandemic has created a dire need for rapid reorganization of health care delivery within surgical services. Ensuing initial reports of high infection rates following endoscopic sinus and skull base surgery, various expert and societal guidelines have emerged. We hereby provide a scoping review of the available literature on endoscopic sinus and skull base surgery, exploring both the risk of aerosolization and expert recommendations on surgical management during the pandemic. Methods A literature search of the PubMed database was performed up until May 9th, 2020. Additionally, websites and published statements from otolaryngology associations were searched for recommendations. This scoping review followed the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews. Results A total of 29 peer-reviewed publications and statements from expert recommendations or professional associations were included. Current expert guidance relies mainly on scarce, anecdotal evidence, and two cadaveric studies, which have demonstrated potential aerosolization during transnasal surgery. General consensus exists for delaying surgery when possible, ascertaining COVID-19 status preoperatively and donning of adequate personal protective equipment by all operating room staff (including at minimum an N95 mask). Cold, nonpowered surgical instruments are deemed the safest, while thermal instruments (electrocautery and laser) and high-speed drills should be minimized. Conflicting recommendations emerge for use of microdebriders. Conclusion Endoscopic sinus and skull base surgery impart a potential risk of aerosolization. Hence, surgical indications, protective measures for health care workers, and surgical instrumentation must be adapted accordingly in the COVID-19 context.
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Papers by Denis Sirhan