Introducing a novel hybrid educational boot camp to augment medical student training in neurosurgery.

OBJECTIVE: Neurosurgery subinternships are a critical portion of the medical student application to neurosurgery residency programs, allowing programs to assess the student's clinical knowledge, interpersonal skills, work ethic, and character. Despite how critical these auditions are, many students have a poor understanding of expectations prior to beginning these subinternships. Thomas Jefferson University hosted a combined in-person and virtual boot camp session open to all medical students interested in neurosurgery. The authors sought to determine the effectiveness of this inaugural course. METHODS: A total of 304 registered participants were sent a survey assessing their attitudes toward neurosurgery subinternships, beliefs about their abilities, and their comfort with various neurosurgical skills. All participants were sent a postsession survey composed of the same questions. The mean scores for responses to pre- and postsession survey questions were recorded based on graduating year and by medical school type (US allopathic [US MD], US osteopathic [US DO], or foreign degree/international medical graduate [IMG]). Differences in means between pre- and postsession survey responses were analyzed using the Student t-test, and statistical significance was set at p < 0.05. RESULTS: A total of 112 presession surveys and 64 postsession surveys were completed, yielding a presession survey response rate of 36.8% and a postsession survey response rate of 21.1%. Seventy-five percent of the postsession survey respondents attended virtually, and 25% were in-person. US MD, US DO, and IMG attendees demonstrated a significantly increased understanding of the expectations of a neurosurgery subintern (p < 0.001). All students had significantly increased confidence in their ability to succeed as subinterns (US MD students and IMGs p < 0.001, US DO students p < 0.05). Regarding procedural confidence, US MD students had increased confidence in craniotomies and cranial plating (p < 0.001). When comparing responses by graduation year, students in the classes of 2024 and 2025 (rising 4th-year and rising 3rd-year medical students, respectively) demonstrated significantly increased understanding of expectations and confidence in their ability to succeed (< 0.001). Seventy-five percent of our postsession survey respondents attended virtually, and 25% were in-person. The in-person cohort had greater improvements in comfort with procedures such as craniotomies, cranial plating, and extraventricular drain placement (in-person vs Zoom mean differences: craniotomies and cranial plating, -2.29, extraventricular drain placement, -2.31) (p < 0.05). CONCLUSIONS: The boot camp successfully delineated the expectations of neurosurgery subinterns and enhanced the attendees' confidence in their abilities. The authors concluded that a hybrid virtual and in-person format is beneficial and feasible in increasing accessibility to information about neurosurgery subinternships.

Internal Neurolysis for Trigeminal Neuralgia: Technical Nuances and a Single-Institution Experience.

BACKGROUND: Trigeminal neuralgia is a facial pain syndrome most commonly caused by a neurovascular compression (NVC) of the trigeminal nerve. Microvascular decompression (MVD) is the most durable surgical treatment; however, patients without an NVC are not candidates for this procedure. Alternative treatments such as percutaneous rhizotomy and radiosurgery are effective but with higher recurrence rates. Internal neurolysis (IN) is a less frequently used procedure that aims to provide long-term relief to patients without NVC. OBJECTIVE: We present the surgical techniques for IN developed at our institution. We also discuss the technical nuances related to nerve consistency and present a new classification based on these findings. We provide pain and numbness outcomes for our cohort of patients stratified by the extent of neurolysis and nerve consistency. METHODS: Patients with medically intractable trigeminal neuralgia eligible for posterior fossa exploration are eligible for MVD and possible IN. If no NVC or a mild NVC is encountered, IN is performed. We have divided the procedure into 4 main steps: opening the outer connective sheath, fascicular dissection, inside-out dissection and the fascicular irrigation technique. Trigeminal nerve consistency has been classified into 3 main types: type 1 is soft and friable; type 2 is intermediate consistency and ideal for neurolysis; and type 3 is firm and presents a more challenging dissection. CONCLUSIONS: In the absence of microvascular compression, we advocate for a thorough neurolysis using the techniques described in our article.

Evolution of Surgical Outcomes in Endoscopic Endonasal Resection of Craniopharyngiomas.

Introduction Wide variations exist in the management of craniopharyngiomas, including pituitary stalk preservation/sacrifice. This study examines the practice patterns over 16 years using the endoscopic endonasal approach for the resection of craniopharyngiomas and it examines the effects of stalk preservation. Methods Retrospective analysis was conducted for 66 patients who underwent endoscopic transsphenoidal surgery for resection of craniopharyngiomas. Patients were stratified into three epochs: 2005 to 2009 ( N = 20), 2010 to 2015 ( N = 23), and 2016 to 2020 ( N = 20), to examine the evolution of surgical outcomes. Subgroup analysis between stalk preservation/stalk sacrifice was conducted for rate of gross total resection, anterior pituitary function preservation, and development of new permanent diabetes insipidus. Results Gross total resection rates across the first, second, and third epochs were 20, 65, and 52%, respectively ( p = 0.042). Stalk preservation across epochs were 100, 5.9, and 52.6% ( p = 0.0001). New permanent diabetes insipidus did not significantly change across epochs (37.5, 68.4, 71.4%; p = 0.078). Preservation of normal endocrine function across epochs was 25, 0, and 23.8%; ( p = 0.001). Postoperative cerebrospinal fluid (CSF) leaks significantly decreased over time (40, 4.5, and 0%; [ p = 0.0001]). Stalk preservation group retained higher normal endocrine function (40.9 vs. 0%; p = 0.001) and less normal-preoperative to postoperative panhypopituitarism (18.4 vs. 56%; p = 0.001). Stalk sacrifice group achieved higher GTR (70.8 vs. 28%, p = 0.005). At last follow-up, there was no difference in recurrence/progression rates between the two groups. Conclusion There is a continuous evolution in the management of craniopharyngiomas. Gross total resection, higher rates of pituitary stalk and hormonal preservation, and low rates of postoperative CSF leak can be achieved with increased surgical experience.

Safety and efficacy of salvage therapy with laser interstitial thermal therapy for malignant meningioma refractory to cesium-131 brachytherapy: illustrative case.

BACKGROUND: Anaplastic meningioma are rare, cancerous tumors of the central nervous system that often require multimodal therapy for tumor control. Both laser interstitial thermal therapy (LITT) and brachytherapy with implanted cesium-131 metallic seeds have demonstrated efficacy in the treatment of recurrent and resistant anaplastic meningioma; however, their safety as a dual therapy has never been reported. OBSERVATIONS: In this report, the authors present a case of a 53-year-old female who received LITT in combination with brachytherapy after surgical and radiation treatment options had been exhausted. The authors discuss the unique safety concern of thermal injury with this treatment combination and demonstrate their method for the safe administration of these treatments together. Furthermore, the authors provide a review of the literature on LITT as an emerging therapy for anaplastic meningioma. LESSONS: The use of LITT in combination with brachytherapy remains an option for salvage therapy in patients with recurrent meningioma that provides durable local control of tumor.

The use of telemedicine in pre-surgical evaluation: a retrospective cohort study of a neurosurgical oncology practice.

PURPOSE: To determine if there was a discrepancy between telemedicine versus in-person New Patient Visits (NPVs) regarding the conversion rate to operative and radiosurgery cases at a tertiary surgical neuro-oncology practice. METHODS: A retrospective analysis was performed of patients who had an outpatient encounter with a neurosurgeon from the Tumor Division at our institution's Department of Neurosurgery between February 1, 2021 and April 30, 2021. NPVs during this period were registered as either telemedicine or in-person appointments. The primary endpoint of the study was to compare the rate at which telemedicine NPVs and in-person NPVs underwent surgery or radiosurgery, reported as the surgical conversion rate. RESULTS: A total of 206 patients were included in this study. Of them, 119 (57.8%) were seen using telemedicine and 87 (42.2%) were seen in clinic via an in-person visit. A total of 70 (34%) of all patients underwent surgery or radiosurgery. Of the 119 patients seen via telemedicine, 40 (33.6%) underwent surgery or radiosurgery; during the same period, 87 NPVs were conducted in person and 30 (34.5%, p = 1.0) received an intervention. Further stratification revealed no differences between the two groups across measured criteria including diagnosis, number of pre-operative visits, elapsed time from appointment to surgery, follow-up visits, and distance from home address to neurosurgical clinic. CONCLUSION: Telemedicine NPVs did not differ significantly from in-person NPVs when evaluating the likelihood of a new patient committing to surgical treatment. This study provides quantifiable evidence that telemedicine is an effective means of meeting new patients and planning complex neurosurgical interventions.

Radiation of meningioma dural tail may not improve tumor control rates.

Introduction: Dural tails are thickened contrast-enhancing portions of dura associated with some meningiomas. Prior studies have demonstrated the presence of tumor cells within the dural tail, however their inclusion in radiation treatment fields remains controversial. We evaluated the role of including the dural tail when treating a meningioma with stereotactic radiation and the impact on tumor recurrence. Methods: This is a retrospective, single-institution, cohort study of patients with intracranial World Health Organization (WHO) grade 1 meningioma and identified dural tail who were treated with stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) from January 2012 to December 2018. SRS and FSRT subgroups were categorized based on coverage or non-coverage of the dural tail by the radiation fields, as determined independently by a radiation oncologist and a neurosurgeon. Demographics, tumor characteristics, radiation plans, and outcomes were evaluated. High grade tumors were analyzed separately. Results: A total of 187 WHO grade 1 tumors from 177 patients were included in the study (median age: 62 years, median follow-up: 40 months, 78.1% female) with 104 receiving SRS and 83 receiving FSRT. The dural tail was covered in 141 (75.4%) of treatment plans. There was no difference in recurrence rates (RR) or time to recurrence (TTR) between non-coverage or coverage of dural tails (RR: 2.2% vs 3.5%, P = 1.0; TTR: 34 vs 36 months, P = 1.00). There was no difference in the rate of radiation side effects between dural tail coverage or non-coverage groups. These associations remained stable when SRS and FSRT subgroups were considered separately, as well as in a high grade cohort of 16 tumors. Conclusion: Inclusion of the dural tail in the SRS or FSRT volumes for meningioma treatment does not seem to reduce recurrence rate. Improved understanding of dural tail pathophysiology, tumor grade, tumor spread, and radiation response is needed to better predict the response of meningiomas to radiotherapy.

A review of multiomics platforms in pituitary adenoma pathogenesis.

Pituitary adenomas (PA), or pituitary neuroendocrine tumors (PitNETs), represent 15% of all central nervous system tumors. Classic description of PitNETs solely by hormonal classification has given way to key transcription factors that play a role in the pathology of PitNETs including steroidogenic factor-1 (SF-1), t-box pituitary transcription factor (TPIT), and pituitary transcription factor 1 (PIT-1). Germline mutations in various familial PitNETs are discussed including those in familial isolated pituitary adenoma (FIPA), multiple endocrine neoplasia (MEN), neurofibromatosis 1 (NF1), and Carney complex. Recent advances in next generation sequencing have improved insight into the pathogenesis of PitNETs. A review of key studies in evaluating the genomic analysis of PitNETs was performed. Chromosomal mutations, whole exome sequencing, microRNA genomics, methylomics and transcriptomics were analyzed. Moreover, the multiomic analysis of various genomic panels has helped to better understand PA classification.

Delayed symptomatic hyponatremia in transsphenoidal surgery: Systematic review and meta-analysis of its incidence and prevention with water restriction.

BACKGROUND: Delayed symptomatic hyponatremia (DSH) is an unpredictable postoperative complication after transsphenoidal pituitary surgery. Universal postoperative sodium screening and water restriction are two strategies to detect or prevent the development of DSH. We performed a meta-analysis of studies characterizing the rate of DSH using sodium screening and water restriction protocols. METHODS: Literature search was done using MEDLINE/PUBMED, EMBASE, and Cochrane databases. Inclusion criteria are (1) development of DSH after endoscopic or microscopic transsphenoidal, sellar surgery, and (2) reporting of a standardized postoperative sodium screening protocol for monitoring or prevention of DSH. RESULTS: A total of 23 publications fulfilled the inclusion criteria resulted in a total of 5870 patients. Two meta-analyses were conducted. Of the 19 studies (N = 4488 patients) examining rate of DSH after sodium screening, DSH rates ranged from 0% to 19.7%. In the first meta-analysis, using a random-effect estimate of the combined proportions, the overall rate of DSH was 5.60% (4.0%-7.1%, I2 = 96.54%, T2 = 0.0007). In the second meta-analysis, a fixed-effect model of four studies consisted of 1382 patients. Eight hundred fifty-two patients were included prior to and 530 were included after water restriction protocol. Meta-analysis showed an odds ratio (OR) of 5.02 (95% CI: 2.16-11.65) favoring water restriction. CONCLUSION: This meta-analysis summarized rates of DSH with sodium screening protocol to be 5.60% (4.0%-7.1%) and showed a decreased risk of DSH after implementation of a water restriction protocol. The results are limited due to few studies examining fluid restriction (N = 4) and heterogeneity in water restriction protocols. No adverse events were seen with fluid restriction protocol. Prospective and multicenter studies should be conducted to further investigate the utility of water restriction following transsphenoidal pituitary surgery.

Evaluation of early postoperative day 1 discharge after endoscopic endonasal pituitary adenoma resection.

OBJECTIVE: While multiple studies have evaluated the length of stay after endonasal transsphenoidal surgery (ETS) for pituitary adenoma, the potential for early discharge on postoperative day 1 (POD 1) remains unclear. The authors compared patients discharged on POD 1 with patients discharged on POD > 1 to better characterize factors that facilitate early discharge after ETS. METHODS: A retrospective chart review was performed for patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from February 2005 to February 2020. Discharge on POD 1 was defined as a discharge within 24 hours of surgery. RESULTS: A total of 726 patients (mean age 55 years, 52% male) were identified, of whom 178 (24.5%) patients were discharged on POD 1. These patients were more likely to have pituitary incidentaloma (p = 0.001), require dural substitutes and DuraSeal (p = 0.0001), have fewer intraoperative CSF leaks (p = 0.02), and have lower postoperative complication rates (p = 0.006) compared with patients discharged on POD > 1. POD 1 patients also showed higher rates of macroadenomas (96.1% vs 91.4%, p = 0.03) and lower rates of functional tumors (p = 0.02). POD > 1 patients were more likely to have readmission within 30 days (p = 0.002), readmission after 30 days (p = 0.0001), nasal synechiae on follow-up (p = 0.003), diabetes insipidus (DI; 1.7% vs 9.8%, p = 0.0001), postoperative hypocortisolism (21.8% vs 12.1%, p = 0.01), and postoperative steroid usage (44.6% vs 59.7%, p = 0.003). The number of patients discharged on POD 1 significantly increased during each subsequent time epoch: 2005-2010, 2011-2015, and 2016-2020 (p = 0.0001). On multivariate analysis, DI (OR 7.02, 95% CI 2.01-24.57; p = 0.002) and intraoperative leak (OR 2.02, 95% CI 1.25-3.28; p = 0.004) were associated with increased risk for POD > 1 discharge, while operation epoch (OR 0.46, 95% CI 0.3-0.71; p = 0.0001) was associated with POD 1 discharge. CONCLUSIONS: This study demonstrates that discharge on POD 1 after ETS for pituitary adenomas was safe and feasible and without increased risk of 30-day readmission. On multivariate analysis, surgical epoch was associated with decreased risk of prolonged length of stay, while factors associated with increased risk of prolonged length of stay included DI and intraoperative CSF leak. These findings may help in selecting patients who are deemed reasonable for safe, early discharge after pituitary adenoma resection.

Management of Coincident Pituitary Macroadenoma and Cavernous Carotid Aneurysm: A Systematic Literature Review.

Introduction Pituitary adenomas are a common intracranial pathology with an incidence of 15 to 20% in the population while cerebral aneurysms are less common with a prevalence of 1:50 patients. The incidence of aneurysms in patients with pituitary adenoma has been estimated at 2.3 to 5.4% of patients; however, this remains unclear. Equally, the management of concomitant lesions lacks significant understanding. Methods A case report is presented of a concomitant cerebral aneurysm and pituitary adenoma managed by minimally invasive endovascular and endoscopic methods, respectively. A systematic review of the literature for terms "pituitary adenoma" and "aneurysm" yielded 494 studies that were narrowed to 19 relevant articles. Results We report a case of a 67-year-old patient with an enlarging pituitary macroadenoma, cavernous carotid aneurysm, and unilateral carotid occlusion. After successful treatment of the aneurysm by a pipeline flow diverter, the pituitary adenoma was surgically resected by an endoscopic transsphenoidal approach. Conclusion The use of a pipeline flow diverter and endonasal approach was feasible in the treatment of our patient. This is the first report to our knowledge of the use of pipeline flow diversion in the management of a cavernous carotid aneurysm prior to pituitary adenoma treatment.

Granulomatosis with polyangiitis masquerading as pituitary adenoma with apoplexy.

Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a small- and medium-vessel autoimmune vasculitis. Rare presentations of GPA can manifest as ophthalmologic and endocrinological deficits with sellar enhancement on imaging. While GPA typically presents distinct in appearance from other sellar pathologies, such as pituitary adenoma, we report the case of a 41-year-old woman with GPA of the pituitary that was initially diagnosed as pituitary macroadenoma with apoplexy and treated with two surgical resections without improvement of clinical symptoms. Pathology analysis of the second resection specimen revealed an inflammatory process consistent with GPA. After the pathologic and clinical diagnosis of GPA was established, treatment with steroid and steroid-sparing immunosuppressants resulted in improvements both on imaging and symptomatically. We discuss important aspects of the diagnosis and treatment of this rare presentation of GPA.

Glioma Stem Cells as Immunotherapeutic Targets: Advancements and Challenges.

Glioblastoma is the most common and lethal primary brain malignancy. Despite major investments in research into glioblastoma biology and drug development, treatment remains limited and survival has not substantially improved beyond 1-2 years. Cancer stem cells (CSC) or glioma stem cells (GSC) refer to a population of tumor originating cells capable of self-renewal and differentiation. While controversial and challenging to study, evidence suggests that GCSs may result in glioblastoma tumor recurrence and resistance to treatment. Multiple treatment strategies have been suggested at targeting GCSs, including immunotherapy, posttranscriptional regulation, modulation of the tumor microenvironment, and epigenetic modulation. In this review, we discuss recent advances in glioblastoma treatment specifically focused on targeting of GCSs as well as their potential integration into current clinical pathways and trials.

A comparative study of transradial versus transfemoral approach for flow diversion.

PURPOSE: Data in neurointerventional literature is extremely limited regarding the safety and efficacy of flow diversion using transradial access (TRA). We aim to demonstrate the safety and efficacy of intracranial aneurysm treatment with the Pipeline Embolization Device (PED) using TRA compared to transfemoral access (TFA). METHODS: We conducted a retrospective analysis of a prospectively maintained database and identified 79 consecutive patients who underwent neuroendovascular embolization for cerebral aneurysms using the PED from April 2018 through October 2019. Patients were divided into 2 groups: TRA (32 patients) and TFA (47 patients). A comparative analysis was performed between the two groups. RESULTS: There was no significant difference in postoperative intracranial hemorrhage (p>.99), symptomatic ischemic stroke (p=.512), access site complications (p=.268), or other complications (p=.512). However, there was a significant increase in overall complications (14.9% vs. 0.0%, p=.038) and procedure duration (71.4 min ± 31.2 vs. 58.5 ± 20.3, p=.018) in the TFA group. There was no significant difference in complete occlusion at latest follow-up (19/25, 76.0% vs. 35/40, 87.5%; p=.311), 6-month follow-up (17/23, 73.9% vs. 33/38, 86.8%; p=.303), or 12-month follow-up (8/8, 100.0% vs. 5/6, 83.3%; p=.429). There was also no significant difference in rate of retreatment (p>.99), morbidity (p=.512), mortality (p>.99), latest follow-up (p=.985), or loss of follow-up (p=.298). CONCLUSIONS: The feasibility and efficacy of flow diversion with the PED via TRA for the treatment of intracranial aneurysms is comparable to TFA. Widespread adoption of this approach may be facilitated by improvements in device navigation and manipulation via radial-specific engineering.

Carotid Blowout Management in the Endovascular Era.

BACKGROUND: Carotid blowout syndrome (CBS) is a potential complication of head and neck cancer, and its therapy is associated with high morbidity and mortality. Recent advances in endovascular techniques have improved patient outcomes. In this study, we report outcomes of emergent endovascular intervention for CBS. METHODS: We conducted a retrospective analysis of a prospectively maintained neurovascular database and identified 38 consecutive endovascular procedures for CBS from 2008-2019 at our institution. Data collection was performed on patient demographics, type of cancer, previous cancer treatments, type of CBS, location of bleed, diagnostic workup, endovascular treatment, and procedural outcomes and complications. RESULTS: A total of 38 consecutive endovascular procedures for CBS were performed from 2008-2019 at our single academic institution. Technical success was achieved in 100% of endovascular procedures. Procedural stroke occurred in 1 (2.6%) procedure, procedural mortality occurred in 1 (2.6%) procedure, recurrent CBS occurred in 4 (10.5%) procedures, and fatal rehemorrhage occurred in 1 (2.6%) procedure. Regarding secondary outcomes, delayed stroke/transient ischemic attack occurred in 1 (2.6%) procedure, whereas there were no cases of delayed infectious complications. CONCLUSIONS: The endovascular treatment of CBS is safe and effective with relatively low rates of morbidity and mortality compared with other currently available treatment modalities. However, the overall rate of complications demands attention and sheds light on the need for further improvement in management.

Glioblastoma Mimicking Viral Encephalitis Responds to Acyclovir: A Case Series and Literature Review.

Viral encephalitis and glioblastoma are both relatively rare conditions with poor prognoses. While the clinical and radiographic presentations of these diseases are often distinctly different, viral encephalitis can sometimes masquerade as glioblastoma. Rarely, glioblastoma can also be misdiagnosed as viral encephalitis. In some cases where a high-grade glioma was initially diagnosed as viral encephalitis, antiviral administration has proven effective for relieving early symptoms. We present three cases in which patients presented with symptoms and radiographic findings suggestive of viral encephalitis and experienced dramatic clinical improvement following treatment with acyclovir, only to later be diagnosed with glioblastoma in the region of suspected encephalitis and ultimately succumb to tumor progression.

Human cytomegalovirus seropositivity is associated with decreased survival in glioblastoma patients.

BACKGROUND: Human cytomegalovirus (HCMV) is an oncomodulatory human herpesvirus that has been detected in glioblastoma (GBM) and is associated with worse prognosis in patients with the disease. The effects of HCMV systemic infection on survival in GBM patients, however, are largely unknown. We aimed to determine the association between HCMV serostatus at diagnosis and survival via a retrospective cohort study of GBM patients. METHODS: Plasma from 188 GBM patients treated at the Ben and Catherine Ivy Center (Seattle, WA) was tested for HCMV serostatus via enzyme-linked immunosorbent assays of anti-HCMV immunoglobulin (Ig)G. HCMV IgG serostatus was analyzed with respect to each patient's progression-free and overall survival (OS) via log-rank and multivariable Cox regression analysis. RESULTS: Ninety-seven of 188 (52%) patients were anti-HCMV IgG seropositive. Median OS was decreased in the IgG+ cohort (404 days) compared to IgG- patients (530 days; P = .0271). Among O 6-methylguanine-DNA methyltransferase (MGMT) unmethylated patients (n = 96), median OS was significantly decreased in IgG+ patients (336 days) compared to IgG- patients (510 days; P = .0094). MGMT methylation was associated with improved OS in IgG+ patients versus those who were unmethylated (680 vs 336 days; P = .0096), whereas no such association was observed among IgG- patients. CONCLUSIONS: In this study, HCMV seropositivity was significantly associated with poorer OS in GBM patients. This finding suggests prior infection with HCMV may play an important role in GBM patient outcomes, and anti-HCMV antibodies may, therefore, prove a valuable prognostic tool in the management of GBM patients.

Fatal Balamuthia mandrillaris brain infection associated with improper nasal lavage.

We report the case of a 69-year-old female who presented with a chronic nasal skin rash, new onset focal seizure, and a cerebral ring-enhancing lesion after a year of improper nasal irrigation. Despite aggressive and novel anti-amoebic treatment, she died as a result of a Balamuthia mandrillaris brain infection.