Identification of risk factors associated with leptomeningeal disease after resection of brain metastases.

OBJECTIVE: Resection of brain metastases (BMs) may be associated with increased risk of leptomeningeal disease (LMD). This study examined rates and predictors of LMD, including imaging subtypes, in patients who underwent resection of a BM followed by postoperative radiation. METHODS: A retrospective, single-center study was conducted examining overall LMD, classic LMD (cLMD), and nodular LMD (nLMD) risk. Logistic regression, Cox proportional hazards, and random forest analyses were performed to identify risk factors associated with LMD. RESULTS: Of the 217 patients in the cohort, 47 (21.7%) developed postoperative LMD, with 19 cases (8.8%) of cLMD and 28 cases (12.9%) of nLMD. Six-, 12-, and 24-month LMD-free survival rates were 92.3%, 85.6%, and 71.4%, respectively. Patients with cLMD had worse survival outcomes from the date of LMD diagnosis compared with nLMD (median 2.4 vs 6.9 months, p = 0.02, log-rank test). Cox proportional hazards analysis identified cerebellar/insular/occipital location (hazard ratio [HR] 3.25, 95% confidence interval [CI] 1.73-6.11, p = 0.0003), absence of extracranial disease (HR 2.49, 95% CI 1.27-4.88, p = 0.008), and ventricle contact (HR 2.82, 95% CI 1.5-5.3, p = 0.001) to be associated with postoperative LMD. A predictive model using random forest analysis with an area under the receiver operating characteristic curve of 0.87 in a test cohort identified tumor location, systemic disease status, and tumor volume as the most important factors associated with LMD. CONCLUSIONS: Tumor location, absence of extracranial disease at the time of surgery, ventricle contact, and increased tumor volume were associated with LMD. Further work is needed to determine whether escalating therapies in patients at risk of LMD prevents disease dissemination.

Safety of Incision Placement with Nipple-sparing Mastectomy and Immediate Prepectoral Breast Reconstruction.

In nipple-sparing mastectomy, adequate perfusion to the nipple-areolar complex (NAC) during reconstruction is paramount to avoiding unwanted outcomes. Previous studies have suggested that periareolar incisions may result in higher rates of NAC complications. However, studies to date have not specifically investigated this in prepectoral reconstruction. The purpose of this study is to evaluate the impact of incision location on NAC complications in patients undergoing prepectoral breast reconstruction. Methods: We performed a retrospective review of all patients who underwent immediate two-stage prepectoral breast reconstruction following nipple-sparing mastectomy between 2015 and 2018 at a single institution. We identified two types of incisions utilized: superior periareolar or inframammary fold (IMF). Patient demographics, comorbidities, and surgical details were compared between incision types, as were NAC complications. Results: A total of 181 consecutive prepectoral breast reconstructions were included for analysis. A superior periareolar incision was used in 113 reconstructions (62%), and an IMF incision was used in 68 reconstructions (38%). There were 33 (18%) total NAC complications in our series. The periareolar incision group had a higher rate of any NAC complication (25% versus 7.4%; P < 0.01), as well as a higher rate of nipple necrosis requiring debridement (9.7% versus 1.5%; P = 0.03). Conclusions: In patients undergoing immediate two-stage prepectoral breast reconstruction following nipple-sparing mastectomy, periareolar incisions are associated with an increased risk of NAC complications compared with IMF incisions. For patients who are candidates for either an IMF or periareolar incision, a periareolar incision should be avoided.

Evaluation of Dual-port versus Single-port Tissue Expanders in Postmastectomy Breast Reconstruction.

BACKGROUND: Immediate tissue expander placement in postmastectomy breast reconstruction can be complicated by seroma or infection, requiring further imaging studies or interventions. This study compares dual-port tissue expanders, with both an aspiration and expansion port, with single-port expanders in terms of postoperative complications and further interventions. METHODS: Patients with immediate tissue expander placement from March 2019 to March 2020 were reviewed. Complications included seroma, infection, hematoma, necrosis, and malposition of the expander. Further intervention included aspiration, ultrasound imaging, interventional radiology (IR) drainage, or return to operating room. RESULTS: In total, 128 dual-port expanders were compared with 125 single-port expanders. Patients with single-port expanders were younger (P = 0.022) and of lower BMI (P = 0.01). There were no significant differences in key complications between these groups. In multivariate analysis, single-port expanders had a 3.4× higher odds of postoperative ultrasound imaging when controlling for texture, placement, and age (P = 0.01). Mean time to IR drain placement in the dual-port group was approximately 30 days after placement in single port (51.1 versus 21.4 days, P = 0.013). Thirty-four percent of dual-port expanders had at least one aspiration in clinic performed by plastic surgery, versus 2% of single port that required ultrasound-guided aspiration (P < 0.001). CONCLUSIONS: There were no differences in key postoperative complications between the two expander cohorts. Dual-port expanders significantly reduced postoperative ultrasound imaging, and delayed IR drain placement. The added convenience of clinic aspirations likely reduced costs related to utilization of resources from other departments.

Cerebrospinal Fluid Leaks and Pseudomeningocele after Posterior Fossa Surgery: Effect of an Autospray Dural Sealant.

Background Posterior fossa craniotomies can be complicated by cerebrospinal fluid (CSF) leaks, infection, meningitis, neurologic deficits, and intracranial hypotension caused by defective closure of the dura. Secondary dural closures such as pericranial graft, muscle graft, glue, sealants, or fat graft are used. However, there have been few studies examining the use of sealants with a polyethylene glycol and polyethylenimine component. Objective We studied the effect of one such sealant, Adherus® (HyperBranch Medical Technology, Durham, NC, USA), as an adjunct to secondary closure methods in the reduction of the use of abdominal fat grafting and lumbar puncture/drains. Methods We retrospectively reviewed the surgical records of all patients undergoing posterior fossa cranial surgery during a two-year period at a tertiary university affiliated medical center. Results Overall, data a total of 122 patients (62 in the no Adherus and 60 in the Adherus group) were collected. There was no statistically significant difference in the 30-day incisional CSF leak rate (4.1% vs. 6.5%; p=0.183), 30-day non-incisional CSF leak rate (11.3% vs. 5.0%; p=0.205), and 30-day pseudomeningocele rate (16.1% vs. 13.3%; p=0.663) in the no Adherus and Adherus groups, respectively. However, there was a significant reduction in the use of abdominal fat grafting (0% vs. 30.7%; p<0.001) and intraoperative CSF diversion techniques (58.1% vs. 23.3%; p<0.001). Every instance of the use of Adherus saved on average, $809.36. Conclusions A statistically significant reduction in the use of CSF shunting procedures during posterior fossa craniotomy/craniectomy was achieved after the introduction of Adherus with no increase in CSF leak rate.

A Safe Transitions Pathway for post-craniotomy neurological surgery patients: high-value care that bypasses the intensive care unit.

OBJECTIVE: High-value medical care is described as care that leads to excellent patient outcomes, high patient satisfaction, and efficient costs. Neurosurgical care in particular can be expensive for the hospital, as substantial costs are accrued during the operation and throughout the postoperative stay. The authors developed a "Safe Transitions Pathway" (STP) model in which select patients went to the postanesthesia care unit (PACU) and then the neuro-transitional care unit (NTCU) rather than being directly admitted to the neurosciences intensive care unit (ICU) following a craniotomy. They sought to evaluate the clinical and financial outcomes as well as the impact on the patient experience for patients who participated in the STP and bypassed the ICU level of care. METHODS: Patients were enrolled during the 2018 fiscal year (FY18; July 1, 2017, through June 30, 2018). The electronic medical record was reviewed for clinical information and the hospital cost accounting record was reviewed for financial information. Nurses and patients were given a satisfaction survey to assess their respective impressions of the hospital stay and of the recovery pathway. RESULTS: No patients who proceeded to the NTCU postoperatively were upgraded to the ICU level of care postoperatively. There were no deaths in the STP group, and no patients required a return to the operating room during their hospitalization (95% CI 0%-3.9%). There was a trend toward fewer 30-day readmissions in the STP patients than in the standard pathway patients (1.2% [95% CI 0.0%-6.8%] vs 5.1% [95% CI 2.5%-9.1%], p = 0.058). The mean number of ICU days saved per case was 1.20. The average postprocedure length of stay was reduced by 0.25 days for STP patients. Actual FY18 direct cost savings from 94 patients who went through the STP was $422,128. CONCLUSIONS: Length of stay, direct cost per case, and ICU days were significantly less after the adoption of the STP, and ICU bed utilization was freed for acute admissions and transfers. There were no substantial complications or adverse patient outcomes in the STP group.

Meningioma metastases: incidence and proposed screening paradigm.

OBJECTIVE: Extracranial meningioma metastases are uncommon, occurring in less than 1% of patients diagnosed with meningioma. Due to the rarity of meningioma metastases, patients are not routinely screened for distant disease. In this series, we report their experience with meningioma metastases and results of screening for metastases in select patients with recurrent meningiomas. METHODS: All patients undergoing resection or stereotactic radiosurgery for primary or recurrent meningioma from 2009 to 2017 at a single center were retrospectively reviewed to identify patients who were diagnosed with or underwent imaging to evaluate for systemic metastases. Imaging to evaluate for metastases was performed with CT scanning of the chest, abdomen, and pelvis or whole-body PET/CT using either FDG or 68Ga-DOTA-octreotate (DOTATATE) tracers in 28 patients. Indications for imaging were symptomatic lesions concerning for metastasis or asymptomatic screening in patients with greater than 2 recurrences being evaluated for additional treatment. RESULTS: Of 1193 patients treated for meningioma, 922 (77.3%) patients had confirmed or presumed WHO grade I tumors, 236 (19.8%) had grade II tumors, and 35 (2.9%) had grade III tumors. Mean follow-up was 4.3 years. A total of 207 patients experienced recurrences (17.4%), with a mean of 1.8 recurrences. Imaging for metastases was performed in 28 patients; 1 metastasis was grade I (3.6%), 16 were grade II (57.1%), and 11 were grade III (39.3%). Five patients (17.9%) underwent imaging because of symptomatic lesions. Of the 28 patients screened, 27 patients had prior recurrent meningioma (96.4%), with a median of 3 recurrences. On imaging, 10 patients had extracranial lesions suspicious for metastasis (35.7%). At biopsy, 8 were meningioma metastases, 1 was a nonmeningioma malignancy, and 1 patient was lost to follow-up prior to biopsy. Biopsy-confirmed metastases occurred in the liver (5), lung (3), mediastinum (1), and bone (1). The observed incidence of metastases was 0.67% (n = 8). Incidence increased to 2% of WHO grade II and 8.6% of grade III meningiomas. Using the proposed indications for screening, the number needed to screen to identify one patient with biopsy-confirmed malignancy was 3.83. CONCLUSIONS: Systemic imaging of patients with multiply recurrent meningioma or symptoms concerning for metastasis may identify extracranial metastases in a significant proportion of patients and can inform decision making for additional treatments.

Fertility treatment is associated with multiple meningiomas and younger age at diagnosis.

PURPOSE: Meningiomas are more common in females and 70-80% express the progesterone receptor, raising the possibility that high-dose exogenous estrogen/progesterone exposure, such as occurs during fertility treatments, may increase the risk of developing a meningioma. The goal of this study was to report the incidence of prior fertility treatment in a consecutive series of female meningioma patients. METHODS: A retrospective review (2015-2018) was performed of female patients with meningioma, and those with prior fertility treatment were compared to those without fertility treatment using standard statistical methods. RESULTS: Of 206 female patients with meningioma, 26 (12.6%) had a history of fertility treatments. Patients underwent various forms of assisted reproductive technology including: in vitro fertilization (50.0%), clomiphene with or without intrauterine insemination (34.6%), and unspecified (19.2%). Median follow up was 1.8 years. Tumors were WHO grade I (78.6%) or grade II (21.4%). Patients who underwent fertility treatments presented at significantly younger mean age compared to those who had not (51.8 vs. 57.3 years, p = 0.0135, 2-tailed T-test), and on multivariate analysis were more likely to have multiple meningiomas (OR 4.97, 95% CI 1.4-18.1, p = 0.0154) and convexity/falx meningiomas (OR 4.45, 95% CI 1.7-11.5, p = 0.0021). CONCLUSIONS: Patients in this cohort with a history of fertility treatment were more likely to present at a younger age and have multiple and convexity/falx meningiomas, emphasizing the importance of taking estrogen/progesterone exposure history when evaluating patients with meningioma. Future clinical studies at other centers in larger populations and laboratory investigations are needed to determine the role of fertility treatment in meningioma development.

A Reduced Exogenous Steroid Taper for Postoperative Brain Tumor Patients-A Case-Control Study.

BACKGROUND: Dexamethasone is a standard treatment for cerebral edema after brain tumor surgery. However, its side effects can negatively impact the quality and safety of care provided to patients. Sparse evidence exists in the literature regarding postoperative steroid dosing to guide clinicians. The objective of this study was to determine if a new reduced exogenous steroid taper (REST) protocol would effectively treat postoperative cerebral edema while reducing the incidence of steroid-related side effects including diabetes, hypertension, and insomnia. METHODS: A REST protocol (dexamethasone 38.5 mg tapered over 10 days) was instituted for patients with postoperative brain tumor of a single surgeon. Historical controls treated with a high-dose taper (dexamethasone 117 mg taper over 17 days) were selected to match for baseline characteristics. Outcomes of new or worsened diabetes, hypertension, and insomnia, as well as length of stay (LOS) and 30-day readmission rates, were compared. RESULTS: Twenty-five patients were included in each group. There were no significant differences in baseline characteristics. The REST group received a median of 34.5 mg (interquartile range, 32-41 mg) of dexamethasone, whereas controls received 43 mg (interquartile range, 16-91 mg) (P = 0.04). There was a significant reduction in the incidence of new or worsened hypertension in the REST group (0%) compared with controls (20%, P = 0.02). No difference was seen in the rates of diabetes mellitus, insomnia, LOS, or 30-day readmission rates. CONCLUSIONS: A reduced steroid taper after brain tumor surgery significantly reduced the incidence of hypertension without increasing LOS or 30-day readmissions compared with controls treated with a high-dose taper.

Cost-effectiveness development for the postoperative care of craniotomy patients: a safe transitions pathway in neurological surgery.

OBJECTIVE The authors' institution is in the top 5th percentile for hospital cost in the nation, and the neurointensive care unit (NICU) is one of the costliest units. The NICU is more expensive than other units because of lower staff/patient ratio and because of the equipment necessary to monitor patient care. The cost differential between the NICU and Neuro transitional care unit (NTCU) is $1504 per day. The goal of this study was to evaluate and to pilot a program to improve efficiency and lower cost by modifying the postoperative care of patients who have undergone a craniotomy, sending them to the NTCU as opposed to the NICU. Implementation of the pilot will expand and utilize neurosurgery beds available on the NTCU and reduce the burden on NICU beds for critically ill patient admissions. METHODS Ten patients who underwent craniotomy to treat supratentorial brain tumors were included. Prior to implementation of the pilot, inclusion criteria were designed for patient selection. Patients included were less than 65 years of age, had no comorbid conditions requiring postoperative intensive care unit (ICU) care, had a supratentorial meningioma less than 3 cm in size, had no intraoperative events, had routine extubation, and underwent surgery lasting fewer than 5 hours and had blood loss less than 500 ml. The Safe Transitions Pathway (STP) was started in August 2016. RESULTS Ten tumor patients have utilized the STP (5 convexity meningiomas, 2 metastatic tumors, 3 gliomas). Patients' ages ranged from 29 to 75 years (median 49 years; an exception to the age limit of 65 years was made for one 75-year-old patient). Discharge from the hospital averaged 2.2 days postoperative, with 1 discharged on postoperative day (POD) 1, 7 discharged on POD 2, 1 discharged on POD 3, and 1 discharged on POD 4. Preliminary data indicate that quality and safety for patients following the STP (moving from the operating room [OR] to the neuro transitional care unit [OR-NTCU]) are no different from those of patients following the traditional OR-NICU pathway. No patients required escalation in level of nursing care, and there were no readmissions. This group has been followed for greater than 1 month, and there were no morbidities. CONCLUSIONS The STP is a new and efficient pathway for the postoperative care of neurosurgery patients. The STP has reduced hospital cost by $22,560 for the first 10 patients, and there were no morbidities. Since this pilot, the authors have expanded the pathway to include other surgical cases and now routinely schedule craniotomy patients for the (OR-NTCU) pathway. The potential cost reduction in one year could reach $500,000 if we reach our potential of 20 patients per month.

Recalcitrant Invasive Skin Cancer of the Scalp: Combined Extirpation and Microsurgical Reconstruction Without Cranioplasty.

BACKGROUND: Recurrent invasive skin cancer of the scalp and calvarium is a difficult problem for which universally accepted treatment protocols have not been established. The authors present their 10-year experience with treatment of this specific subset of scalp reconstruction patients and present a successful treatment algorithm that is well suited to this patient population. METHODS: The authors retrospectively reviewed all patients of microsurgical scalp reconstruction performed from 2005 to 2015 that involved invasive cutaneous malignancies of the scalp and calvarium. RESULTS: Eleven patients met inclusion criteria. There were 9 squamous cell carcinoma, 1 basal cell carcinoma, and 1 melanoma. Seven received radiation prior to resection, 2 were irradiated postoperatively, and 2 were immunosuppressed. Seven had a history of prior scalp reconstruction. The median scalp defect size was 141 cm. All the patients underwent craniectomy and the median cranial defect size was 71 cm. Cranioplasty was not performed in any patient. There were no intraoperative complications or flap loss. Recipient site complications included hematoma in 1, 1 seroma, 2 cerebral spinal fluid leaks, 3 partial skin graft loss. There was 1 donor site seroma in a patient who had a latissimus dorsi flap. All the patients reported satisfaction with the overall result and none were limited in activities by the existing cranial defect. CONCLUSIONS: This is the largest series published to date that focuses exclusively on management of cutaneous malignancies with intracranial invasion. Wide resection with craniectomy, and reconstruction with microvascular free tissue transfer without cranioplasty provides safe and reliable treatment of recalcitrant invasive scalp skin cancers with low morbidity and without major complications. Pre and postoperative radiation is well tolerated with this approach. The patients in this series were of advanced age and of a lifestyle for which cranioplasty is unnecessary for return to regular activities.

Surgical resection of fourth ventricular ependymomas: case series and technical nuances.

Ependymomas are rare neuroepithelial tumors which may arise anywhere along the ventricular system. Tumors arising in the fourth ventricle present unique challenges. Complete tumor resection favors prolonged survival, but may result in inadvertent injury of surrounding neural structures-such as cranial nerve (CN) nuclei. Here, our institutional experience with surgical resection of fourth ventricular ependymomas is described. A single institution, retrospective analysis of consecutive case series of adult surgically resected fourth ventricular ependymomas with the bilateral telovelar approach. Extent of resection, outcomes and postoperative complications are statistically analyzed. From January 2000 to April 2016, 22 fourth ventricular ependymomas underwent surgical resection. Gross total resection was achieved in 18 of 22 cases (82 %). There were six postoperative CN palsies-3 lower CN palsies (IX, X, or XI), 1 CN VII palsy, 1 CN IV palsy, and 1 CN VI palsy. No deaths or cerebellar mutism occurred. Two of 6 CN deficits resolved and the rate of permanent neurologic deficit was 18 %. A CN deficit was not statistically associated with prolonged hospital stay or functional outcome. With exception of one patient, all patients functionally improved or remained unchanged following surgery. Postoperative complications included one wound infection (4.5 %) and four pseudomeningoceles (18 %). The rate of shunt-dependent hydrocephalus was 18 %. Tumors adherence to the fourth ventricular floor is not an absolute contraindication for complete resection. Intraoperative neuro-monitoring is essential, and the development of sustained, but not transient CN activity, and/or hemodynamically significant bradycardia should limit the extent of resection.

Stability of Programmable Shunt Valve Settings with Simultaneous Use of the Optune Transducer Array: A Case Report.

The Optune® transducer array (Novocure Ltd., Haifa, Israel) is an FDA-approved noninvasive regional therapy that aims to inhibit the growth of glioblastoma multiforme (GBM) cells via utilization of alternating electric fields. Some patients with GBM may develop hydrocephalus and benefit from subsequent shunt placement, but special attention must be paid to patients in whom programmable valves are utilized, given the potential effect of the magnetic fields on valve settings. We present the first case report illustrating the stability of programmable shunt valve settings in a neurosurgical patient undergoing therapy with the Optune device. In this study, shunt valve settings were stable over a period of five days despite Optune therapy. This is reassuring for patients with GBM who require simultaneous treatment with both the Optune device and a programmable shunt system.