Outcomes and cost-effectiveness of gamma knife radiosurgery and whole brain radiotherapy for multiple metastatic brain tumors

We aimed to analyze the outcomes and cost-effectiveness of gamma knife radiosurgery (GKRS) and whole brain radiotherapy (WBRT) for multiple metastatic brain tumors. Over a period of 5 years, 156 patients with multiple metastatic brain tumors were enrolled and freely assigned by the referring doctors to either gamma knife radiosurgery (GKRS, Group A, n = 56), or to whole brain radiotherapy (WBRT, Group B, n = 100). The follow-up time was set at 1200 days (3.3 years) post-treatment. The number of tumors, patient age, extent of systemic disease and Karnofsky performance scale (KPS) score, were recorded and recursive partitioning analysis used. The outcomes analyzed were: mortality, survival time, neurological complications, post-treatment KPS score, quality-adjusted life years (QALY), and cost-effectiveness. A paired t-test was used for statistical analysis. Mortality rates for patients receiving GKRS and WBRT were 81.1% and 93.0%, respectively (p = 0.05). The mortality rate was lower for GKRS (74.4%) than for WBRT (97.1%) in patients with initial KPS ? 70 (p = 0.02). The mortality rate was also significantly lower for GKRS (78.9%) than WBRT (95.5%) in patients with 2–5 tumors (p < 0.05). Post-treatment KPS score (mean ± standard deviation [s.d.] was higher for patients receiving GKRS (73.8 ± 13.2) than for those receiving WBRT (45.5 ± 26.0), p < 0.01. The median survival time for GKRS and WBRT was 9.5 months and 8.3 months, respectively, p = 0.72. The mean (± s.d.) QALY was 0.76 ± 0.23 for GKRS and 0.59 ± 0.18 for WBRT, respectively (p < 0.05). The cost-effectiveness per unit of QALY was better for the GKRS treatment (US$10,381/QALY) than in the WBRT treatment (US$17,622/QALY), p < 0.05. The cost-effectiveness per KPS score was also higher for the GKRS treatment (US$139/KPS score) than for WBRT (US$229/KPS score), p < 0.01. Thus, the mortality rate for multiple metastatic brain tumors treated by GKRS is significantly better with a good initial KPS score and when the tumor number is 2–5. GKRS results in a better post-treatment KPS score, QALY, and higher cost-effectiveness than WBRT for treating multiple metastatic brain tumors.     

Immediate morbidity and mortality associated with transcallosal resection of tumors of the third ventricle

Resection of tumors of the third ventricle via the anterior interhemispheric transcallosal approach represents a surgical challenge. It carries a risk of postoperative complications, due to the role of surrounding structures in control of eloquent functions. We reviewed the immediate morbidity and mortality associated with this approach. Between June 1993 and July 2007, 38 patients underwent resection of tumors of the third ventricle via the anterior interhemispheric transcallosal approach at The University of Texas M. D. Anderson Cancer Center. Their 30-day postoperative morbidity and mortality rates were retrospectively analyzed relative to clinical variables possibly affecting these rates. Complications were categorized as neurological, regional, and systemic and were subclassified as major or minor. The overall complication rate was 50%. Major complications occurred in 37% of patients; 34% suffered neurological complications (16% being major complications). Surgical mortality was 8%. Univariate analysis demonstrated that tumor hemorrhage (p = 0.04), preoperative Karnofsky Performance Scale (KPS) score (p = 0.04), tumor status (recurrent versus [vs.] new or residual; p = 0.01), and cauterization of any of the bridging veins (p = 0.04) were associated with the incidence of postoperative complications. Multivariate analysis showed that increased age at surgery (p = 0.04), tumor status (p = 0.03), preoperative KPS score (p = 0.02), and the extent of tumor resection (p = 0.05) correlated significantly with the incidence of postoperative complications. Resection of tumors of the third ventricle via the interhemispheric transcallosal approach is associated with significant postoperative morbidity. Preserving the venous structures is of paramount importance in minimizing major neurological complications. Our results have practical risk-predictive value and can serve as the foundation for subsequent outcome studies.     

Increased cerebrospinal fluid concentrations of asymmetric dimethylarginine correlate with adverse clinical outcome in subarachnoid hemorrhage patients

Elevated cerebrospinal fluid (CSF) concentrations of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, have been found in patients with subarachnoid hemorrhage (SAH). In addition, CSF levels of ADMA are associated with the severity of vasospasm. However, the relation between CSF ADMA levels and the clinical outcome of SAH patients is still unclear. We hypothesized that elevated ADMA levels in CSF might be related to the clinical outcome of SAH patients. CSF ADMA levels were measured in 20 SAH patients at days 3–5, days 7–9 and days 12–14 after SAH onset using high-performance liquid chromatography. Cerebral vasospasm was assessed by transcranial Doppler ultra sonography. Clinical outcome at 2 year follow-up was evaluated using the Karnofsky Performance Status scale (KPS). CSF ADMA concentrations in all SAH patients were significantly increased at days 3–5 (p = 0.002) after SAH, peaked on days 7–9 (p < 0.001) and remained elevated until days 12–14 (p < 0.001). In subgroup analysis, significant increases of CSF ADMA levels were found in patients both with and without vasospasm. The KPS scores significantly correlated with CSF levels of ADMA at days 7–9 (correlation coefficient = −0.55, p = 0.012; 95% confidence interval −0.80 to −0.14). Binary logistic regression analysis indicated that higher ADMA level at days 7–9 predicted a poor clinical outcome at 2 year follow-up after SAH (odds ratio = 1.722, p = 0.039, 95% confidence interval 1.029 to 2.882). ADMA may be directly involved in the pathological process and future adverse prognosis of SAH.     

Predictors of aggressive clinical phenotype among immunohistochemically confirmed atypical adenomas

Despite formal pathological criteria, not all atypical pituitary adenomas display clinically aggressive behavior. We set out to determine which factors predict a clinically aggressive phenotype among a cohort of atypical pituitary adenomas. Medical records were retrospectively reviewed from April 2008 to July 2015. Of 569 pituitary adenomas, 47 (8.3%) patients were surgically treated for atypical adenomas as defined by the WHO criteria. Clinically aggressive adenomas were defined as occurring in those patients who necessitated additional therapeutic intervention after the index (first) surgery, including additional surgery, medical therapy, or radiosurgery. Forty-seven patients with histopathological and immunohistochemical confirmation of atypical adenomas were identified and of these, 23 were noted to have a clinically aggressive course. Among the remaining 24 patients, the disease remained quiescent after the index surgery. On univariate analysis, clinically aggressive lesions were more likely to have a larger axial diameter on MRI (2.9 ± 1.9 cm vs. 1.9 ± 0.7 cm, p = 0.02), greater incidence of cavernous sinus invasion (65.2% vs. 20.8%, p < 0.01), and greater incidence of clival extension (60.9% vs. 0, p < 0.01) on preoperative imaging. The two groups were equivalent with regard to immunohistochemical staining for ACTH, HGH, LH, FSH, PRL, and TSH. Clinically aggressive lesions, however, trended towards a greater average MIB-1 proliferative index (7.5% ± 4.9 vs. 6.0% ± 3.6, p = 0.03). On multivariate analysis, the MIB-1 proliferative index trended towards statistical significance (p = 0.06) as an independent predictor of clinical aggressiveness. Atypical pituitary adenomas are defined by a rigid set of immunohistochemical markers, but not all necessarily demonstrate an aggressive clinical phenotype.     

Clinical management and survival of patients with central nervous system hemangiopericytoma in the National Cancer Database

Purpose/objectivesHemangiopericytomas are rare central nervous system (CNS) tumors. We sought to investigate existing clinical management strategies and overall survival (OS) among patients with hemangiopericytomas of the CNS.Methods/materialsAll patients diagnosed with CNS hemangiopericytoma from 2004 to 2014 in the National Cancer Database were included. Clinical and treatment-related characteristics were analyzed for an association with OS following diagnosis using univariable and multivariable analyses.ResultsNine-hundred and eighty-one patients were included (0.22% of all CNS tumors). At diagnosis, 22 patients had spinal tumors (2%), 21 patients had multifocal tumors (2%) 28 had disseminated disease (3%), and the remainder were unifocal intracranial tumors. Patients either underwent surgical resection and radiation (48%), surgery alone (37%), radiation alone (6%), or biopsy alone (9%). Of patients with known extent of resection, 53% underwent gross total resection, and, of patients with known radiation modality, 15% received stereotactic radiosurgery. Among the total cohort, 3 and 10 year OS was 87% and 59%, respectively. On multivariable analysis, factors associated with inferior OS included age (HR = 1.05, p < 0.001), WHO grade (p < 0.001), multifocal disease (HR = 2.59, p = 0.04), disseminated disease (HR = 2.67, p = 0.01), and chemotherapy (HR = 2.66, p = 0.01). Patients receiving surgery alone or surgery and radiation demonstrated improved OS compared to biopsy alone (HR = 0.45, p = 0.01 and HR = 0.47, p = 0.02, respectively). However radiation utilization did not impact OS (p = 0.691).ConclusionsThe present data provide large-scale prognostic information from a contemporary cohort of patients with hemangiopericytoma and support an initial attempt at surgical extirpation. The benefits of ionizing radiation are likely limited to improved local control and neurologic function.     

Aneurysmal acute subdural hemorrhage: Prognostic factors associated with treatment

Acute subdural hematoma is an uncommon presentation of aneurysmal hemorrhage that has been identified as a poor prognostic sign. Current series are small, have short follow-up, or were collected over a long period during which treatment evolved. To evaluate prognostic factors, we analyzed a large modern series of aneurysmal subdural hematoma (aSDH) with long-term follow-up. A prospectively maintained database was queried for patients presenting with aSDH from 2001–2013. Thirty patients met the study criteria. Statistical analysis was performed with unpaired t-test or Fisher’s exact test. Aneurysm treatment involved open clipping (n = 18), endosaccular coiling (n = 8), both (n = 1), or no treatment (n = 3). Good Glasgow Outcome Scale score at discharge was present in 20% and increased to 40% at 6–12 months postoperatively. Good clinical presentation was associated with good final outcome in 75%, whereas poor clinical presentation correlated with good outcome in 30%. Good outcome correlated with younger age (p = 0.04), smaller aneurysm (p = 0.04), and lower Hunt-Hess score (HH) at intervention (p = 0.04). Favorable outcome did not correlate with sex, race, presence of subarachnoid or intraparenchymal hemorrhage, size or laterality of hemorrhage, midline shift, aneurysm treatment modality, or HH at admission (p > 0.15). There was no difference between good and poor outcomes in terms of time to treatment or hematoma evacuation. Poor clinical presentation may be exaggerated by mass effect of hematoma; aggressive treatment is not futile. Presenting neurological status, age, and aneurysm size are predictors of outcome, while laterality and size of hematoma and extent of midline shift are not, suggesting that clinical status is more important than radiographic findings.     

Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage

Background and purposePrimary pontine hemorrhage (PPH) accounts aproximately for about 5–10% of intracranial hemorrhages, and PPHs are known to have a much less uniform prognosis. We aimed to evaluate the clinical and radiological predictors affecting the mortality in 32 patients with PPH.Material and methodsWe retrospectively evaluated the data of 32 patients with PPH admitted to our clinic between 1994 and 2004. We divided the patients into two groups: (1) patients who survived (14 patients), and (2) patients who died (18 patients). The two groups were compared for age, gender, diabetes mellitus, hypertension, initial clinical status, initial GCS, pupillary abnormalities, ophthalmoparesis, volume and localisation of hemorrhage, intraventricular and extrapontine extension, necessity of mechanical ventilation and hydrocephalus. The hematoma volumes were measured with the formulation described by Broderick.ResultsEighteen patients (56%) died and 14 patients (44%) survived. The patients who died (61.3 ± 8.8) were older than the survivors (56.4 ± 11.0), but the difference was not statistically significant. The mean GCS was 4.4 ± 0.2, the mean hematoma volume was 9.9 ± 3.3 ml for patients who died and the mean GCS was 10.1 ± 3.3, the mean hematoma volume was 3.3 ± 1.2 ml for survivors (p < 0.001). Coma on admission (p = 0.001), extrapontine extension (p = 0.001), intraventricular extension (p = 0.019), necessity of mechanical ventilation (p = 0.007), hydrocephalus (p = 0.024), massive and bilateral tegmental localisation (p = 0.006) were found statistically significant predictors for mortality with univariate comparison, and coma on admission (p = 0.038) was the only significant predictor with multivariate regression analysis.ConclusionIn patients with PPH, it is important to know the prognostic factors for mortality for planning the treatment protocol, and coma and bad clinical status on admission was found the only significant prognostic predictor for mortality with multivariate regression analysis.     

Primary lesion location influences postoperative survival in patients with metastatic colorectal spinal lesions

Spinal metastasis from colorectal cancer occurs rarely. However, with increasing incidence of colorectal cancer in the setting of improved therapies, physicians are more likely to encounter such patients. We performed a retrospective review of patients who underwent spine surgery for metastatic colorectal cancer from 2005–2011. Preoperative, operative and postoperative factors; functional outcome as determined by Karnofsky Performance Status (KPS) and modified Rankin scale (mRS); and survival were recorded. Univariate analysis was performed, with patients stratified into two groups based on the position of the primary cancer, either proximal (colon) or distal (rectum) to the rectosigmoid junction. Fourteen patients, with a median age of 52 (interquartile range [IQR] 48–66) years, underwent 21 spine surgeries for metastatic colorectal cancer. Pain was the common presenting symptom (n = 11, 79%), followed by motor weakness (n = 8, 57%). Twenty-seven postoperative complications occurred in 11 (52%) patients. Baseline KPS and mRS remained stable in four (29%), improved in two (14%), worsened in six (43%), and was unknown in two (14%) at last follow-up. Patients with spinal metastasis from a rectal primary (n = 6) had a significantly longer survival compared to those with a colon primary (n = 8), with a median survival of 84 (IQR 56–103) versus 26 (IQR 19–44) months after primary diagnosis (p = 0.002), 19 (IQR 13–27) versus five (IQR 3–9) months after spine metastasis diagnosis (p = 0.010), and six (IQR 4–14) versus three (IQR 2–4) months after surgery (p = 0.030). Patients with spinal metastasis arising from rectal primary lesions display longer survival compared to colon lesions. Consideration of these factors is essential to appropriately assess surgical candidacy.     

Lifetime presence of psychotic symptoms in bipolar disorder is associated with less favorable socio-demographic and certain clinical features

BackgroundThe presence of psychotic symptoms in bipolar disorder (BD) is considered a feature of higher severity of illness and, in particular, of manic episodes in bipolar I disorder (BD I). However, the possibility to apply the “with psychotic features” specifier to major depressive episodes in either bipolar II disorder (BD II) or BD I highlights the need for additional research in this area.MethodsThe present study assessed the lifetime presence of psychotic symptoms and related socio-demographic and clinical features in a large sample of BD patients (N = 360), with (BDPs, N = 207) and without a lifetime history of psychosis (BDNPs, N = 153).ResultsAn overall less favorable socio-demographic profile was observed in BDPs vs BDNPs. In terms of clinical variables, BDPs vs BDNPs had: earlier age at onset (27.7 ± 10.5 vs 30.1 ± 12.3 years; p = 0.02), higher rates of BD I diagnosis (95.7% vs 45.8%; p < 0.001), more elevated (manic/hypomanic/mixed) polarity of first (55.2% vs 24.4%; p < 0.001) and most recent episode (69.8% vs 35.6%; p < 0.001), more comorbid alcohol/substance use disorder (38.1% vs 21.9%; p = 0.002), more lifetime hospitalizations (3.8 ± 6.1 vs 2 ± 3; p = 0.002) and involuntary commitments (1 ± 1.9 vs 0.1 ± 0.4; p < 0.001), more history of psychosocial rehabilitation (17.9% vs 5.7%; p = 0.001), more current antipsychotic use (90.1% vs 70.9%; p < 0.001), and lower GAF (62.3 ± 14.2 vs 69.3 ± 12.5; p < 0.001), but shorter duration of most recent episode (34.1 ± 45.4 vs 50.3 ± 65.7 days; p = 0.04), lower rates of comorbid anxiety disorders (23.9% vs 38.2%; p = 0.005), and antidepressant use (19.4% vs 56.6%; p < 0.001).ConclusionsThe present findings indicate an overall worse profile of socio-demographic and certain clinical characteristics associated with the lifetime presence of psychotic symptoms in bipolar patients.     

Prognostic factors and treatment options for paediatric ependymomas

The aim of this study was to determine factors of prognostic relevance for paediatric ependymomas, and evaluate the efficacy of treatment modalities. This is a retrospective study of 43 patients with ependymoma (<18 years) who underwent a combination of surgical excision, chemotherapy, and/or radiotherapy treatment at The Prince of Wales Cancer Centre between 1969 and 2009. Statistical analysis was performed to assess the prognostic relevance of various parameters affecting the two-year and five-year overall survival (OS) and progression-free survival (PFS). The five-year OS and PFS were 50.3% and 44.8% respectively (median follow-up 50 months). Eighteen patients (41.9%) experienced tumour recurrence: 13 had a local recurrence (LR) and five had both LR and distant recurrence. On univariate analysis, a more favourable prognosis in terms of both OS and PFS was evident for supratentorial tumours compared to infratentorial tumours (OS p = 0.007, PFS p = 0.045), stereotactic radiosurgery/ fractionated stereotactic radiotherapy compared to craniospinal irradiation or local posterior fossa/local brain ± boost radiotherapy modalities (OS p = 0.047, PFS p = 0.031), total radiotherapy dose >50 Gy compared to ?50 Gy (OS p = 0.008, PFS p = 0.005), and in patients with no tumour recurrence compared to those with recurrence (OS p = 0.03, PFS p < 0.001). Although not statistically significant, a more favourable multivariate outcome was evident in patients who underwent complete surgical resection. Chemotherapy treatment and histopathological grade, however, were not relevant to prognosis. This study supports the need to pursue more aggressive treatment for infratentorial and/or recurrent tumours. Ideal treatment involves maximal surgical resection, followed by adjuvant radiotherapy (>50 Gy).     

Prevalence and predictors of carotid stenosis in Thai patients with ocular disorders

There are limited data on prevalence and predictors of carotid stenosis (CS) in Thai and Asian patients with ocular disorders. A total of 135 of 2849 patients enrolled in the Neurosonology Registry had an ocular indication (OI). Demographics, the nature of the OI, risk factors (RF), presence of CS >50% and non-stenotic carotid plaque (NSCP) were analyzed. The mean age of patients was 60.40 ± 14.02 years. The RF included hypertension (47.4%), hypercholesterolemia (34.07%), diabetes mellitus (DM) (31.11%) and current smoking (41.48%). NSCP was found in 20% of Thai patients with OD. CS was found in 11.11% (ipsilateral 10.37%). Predictors of CS were ocular ischemic syndrome (odds ratio [OR] 19.63, p = 0.000), retinal artery occlusion (OR 14.13, p = 0.000), anterior ischemic optic neuropathy (OR 9.75, p = 0.002), neovascularized glaucoma (OR 8.15, p = 0.018), and DM (OR 2.53, p = 0.037). The presence of CS (11.11%), and CS or NSCP (31%) are markers of atherosclerotic risk. The nature of the OI predicted carotid findings. Carotid ultrasound helps to identify the risk for cardiovascular events and should be considered in patients with OI.     

Severity of depressive symptomatology and functional impairment in children and adolescents with temporal lobe epilepsy

ObjectiveDepression is a frequent psychiatric disorder in children with temporal lobe epilepsy (TLE). However, severity of depressive symptoms (DS) is frequently neglected in these patients. This study aimed to determine severity of DS and global functioning by using quantitative measures and to establish their correlation with patients’ demographics and clinical variables.Methods31 children (mean age of 11.8 ± 2.3 years) with TLE were assessed with K-SADS-PL for axis I DSM-IV diagnosis. Severity of DS was measured by Children Depression Rating Scale-Revised – CDRS-R. Global functional impairment was evaluated with Child Global Assessment Scale-CGAS.Results25 patients (56% boys; 12 ± 2.3 years) had current DS, moderate or severe in 84% according to CDRS-R T-Score. Severity of DS was not correlated with age (p = 0.377), gender (p = 0.132), seizure control (p = 0.936), age of onset (p = 0.731), duration of epilepsy (p = 0.602) and the presence of hippocampal sclerosis (p = 0.614). Patients had moderate to major functional impairment measured by CGAS (48.7 ± 8.8), being adolescents more impaired than children (p = 0.03). Impairment of global functioning was not associated with epilepsy variables (p > 0.05).ConclusionChildren with TLE had moderate to severe DS early in the course of their disease with a relevant impact on their global functional activities, especially considering adolescents. Epilepsy severity seems not to be correlated to the severity of DS, contradicting the idea of a cause–consequence relationship. More systematic research is needed to better understand the association of depressive disorders in children and adolescents with TLE.     

Sleep syncope: Important clinical associations with phobia and vagotonia

ObjectivesTo compare demographic and clinical data from patients with sleep syncope to those of patients with “classical” vasovagal syncope [VVS] collected over the last 8 years.DesignRetrospective case-controlled study.SettingSyncope unit.Patients and methodsFifty-four patients with a history suggestive of one or more episodes of sleep syncope (group SS) were matched for age and gender to 108 patients with VVS (control group).A syncope questionnaire was completed immediately before tilt-testing and included frequency, age-of-onset and severity of episodes; situations, postures and perceived triggers; lifetime prevalence of specific phobias; and symptoms during syncope.ResultsGroup SS were mainly women (65%), mean age of 46 ± 2.1 years, with a mean lifetime total of 5.4 ± 0.83 episodes of sleep syncope. Compared to controls, SS episodes were more likely to start in childhood, 26.9% versus 50% (p = 0.005), and more severe, score 2.40 ± 0.11 versus 2.81 ± 0.15 (p = 0.03). In group SS: syncope onset whilst lying down was more frequent, 4.6% versus 32.7% (p = 0.001); the lifelong prevalence of any specific phobia was higher, 32.4% versus 74.5% (p = 0.001), in particular blood injection injury (BII) phobia, 19.4% versus 57.4% (p = 0.001); and during attacks, distressing vagal symptoms were more frequent, e.g., abdominal discomfort, 13.9% versus 72.2% (p = 0.001).ConclusionSleep syncope is not rare and is characterised by lifelong, intermittent but severe episodes of vasovagal syncope which may occur in the horizontal position, with distressing abdominal symptoms. BII phobia is strongly associated and may be a predisposing factor or a co-existent disorder in these patients.     

Positron emission tomography findings in children with infantile spasms and autism

The purpose of this study was to evaluate positron emission tomography (PET) findings in patients diagnosed with infantile spasms and autism. This study includes 90 patients who were diagnosed with infantile spasms at the Department of Pediatric Neurology in the Istanbul University Medical Faculty between 1995 and 2007. Of the 90 patients, 15 patients who were diagnosed with autism using the Autism Behaviour Checklist and Childhood Autism Rating Scale and a control group of nine patients without autism but with infantile spasms underwent PET examination. Mean patient age (± standard error, SE) varied between 3 years and 16 years (7.8 ± 4 years), while the mean follow-up time (±SE) varied between 2 years and 16 years (average: 7.1 ± 4 years). Autism was present in 11 patients with symptomatic spasms and in four patients with cryptogenic spasms (p = 0.009). On the PET scans of the 15 patients with autism, 13 (86.7%) had significantly decreased metabolic activity in the temporal lobe (p < 0.001), nine (60%) had significantly decreased activity in the frontal lobe (p = 0.004), and seven (46.7%) had significantly decreased activity in the parietal lobe (p = 0.022). In our opinion, hypometabolism in the frontal and parietal lobes, in addition to that previously reported in the temporal lobe, plays a role in the development of autism in patients with infantile spasms.     

Sleep and cardiometabolic function in obese adolescent girls with polycystic ovary syndrome

ObjectiveTo compare the polysomnography findings and cardiometabolic function among adolescent girls with polycystic ovary syndrome (PCOS) and matched female and male controls.MethodRetrospective chart review of electronic medical records of 28 girls with PCOS (age: 16.8 ± 1.9 years, body mass index (BMI) Z-score 2.4 ± 0.4), 28 control females (age: 17.1 ± 1.8, BMI Z-score 2.4 ± 0.3) and 28 control males (age: 16.6 ± 1.6, BMI Z-score 2.5 ± 0.5) in a tertiary care centre.ResultsThe prevalence of obstructive sleep apnoea (OSA) was higher in girls with PCOS compared to control females (16/28 (57%) vs. 4/28(14.3%), p < 0.01); however, it was comparable to that of the control males (16/28(57%) vs. 21/28(75%), p = 0.4). Girls with PCOS had a significantly higher prevalence of insulin resistance compared to control females and control males (20/28 (71.4%) vs. 9/22 (41.0%) (p = 0.04) vs. 8/23 (34.8%) (p = 0.01). Among girls with PCOS, those with OSA had significantly higher proportions of metabolic syndrome (MetS) (9/16 (56.3%) vs. 1/12 (8.3%) p = 0.03), higher insulin resistance (14/16 (87.5%) vs. 6/12 (50%), p = 0.04), elevated daytime systolic blood pressure (128.4 ± 12.8 vs. 115.6 ± 11.4, p < 0.01), lower high-density lipoprotein (HDL) (38.6 ± 8.7 vs. 49 ± 10.9, p = 0.01) and elevated triglycerides (TG) (149.7 ± 87.7 vs. 93.3 ± 25.8, p = 0.03) compared to those without OSA.ConclusionsWe report a higher prevalence of OSA and metabolic dysfunction in a selected group of obese girls with PCOS referred with sleep-related complaints compared to BMI-matched control girls without PCOS. We also report higher prevalence of cardiometabolic dysfunction in girls with PCOS and OSA compared to girls with PCOS without OSA.     

Traumatic interhemispheric subdural haematoma: Study of 35 cases

The clinical and radiological findings, management, and outcomes in 35 patients with traumatic interhemispheric subdural haematoma (ISH) were reviewed retrospectively. Twenty-five patients had favourable outcomes and 10 had poor outcomes. All patients were treated conservatively for ISH. Univariate analysis found that the Glasgow Coma Scale (GCS) score (p < 0.001), hypovolemic shock (p = 0.018), skull fracture (p = 0.008), convexity or posterior fossa subdural haematoma (p = 0.008), and subarachnoid haemorrhage (SAH) were correlated with outcome (p < 0.001). Multivariate analysis showed that GCS score (p = 0.031; odds ratio [OR], 0.6; 95% confidence interval [CI], 0.3–0.9) and the presence of SAH (p = 0.023; OR, 14.2; 95% CI, 1.5–138.2) were significantly related to poor outcome. This study provides important information on the clinicoradiological findings and prognoses in patients with traumatic ISH.     

Outcome and prognostic factors in adult cerebellar glioblastoma

Cerebellar glioblastoma multiforme (GBM) occurs rarely in adults, accounting for 0.4–3.4% of all GBM. Current studies have all involved small patient numbers, limiting the clear identification of prognostic factors. Additionally, while few studies have compared cerebellar GBM to their supratentorial counterparts, there is conflicting data regarding their relative prognosis. To better characterize outcome and identify patient and treatment factors which affect survival, the authors analyzed cases of adult cerebellar GBM from the Surveillance, Epidemiology, and End Results database. A total of 247 adult patients with cerebellar GBM were identified, accounting for 0.67% of all adult GBM. Patients with cerebellar GBM were significantly younger than those with supratentorial tumors (56.6 versus 61.8 years, p < 0.0001), but a larger percentage of patients with supratentorial GBM were Caucasian (91.7% versus 85.0%, p < 0.0001). Overall median survival did not differ between those with cerebellar and supratentorial GBM (7 versus 8 months, p = 0.24), with similar rates of long-term (greater than 2 years) survival (13.4% versus 10.6%, p = 0.21). Multivariate analysis revealed age greater than 40 years (hazard ratio [HR]: 2.20; 95% confidence interval [CI]: 1.47–3.28; p = 0.0001) to be associated with worse patient survival, while the use of radiotherapy (HR: 0.33; 95% CI: 0.24–0.47; p < 0.0001) and surgical resection (HR: 0.66; 95% CI: 0.45–0.96; p = 0.028) were seen to be independent favorable prognostic factors. In conclusion, patients with cerebellar GBM have an overall poor prognosis, with radiotherapy and surgical resection significantly improving survival. As with supratentorial GBM, older age is a poor prognostic factor. The lack of differences between supratentorial and cerebellar GBM with respect to overall survival and prognostic factors suggests these tumors to be biologically similar.     

Outcomes and patterns of care in adult skull base chordomas from the Surveillance,Epidemiology, and End Results (SEER) database

This study aims to demonstrate survival rates and treatment patterns among patients with chordomas of the skull base using a large population database. Patients with cranial chordomas between 1973 and 2009 were identified from the USA Surveillance, Epidemiology, and End Results (SEER) public use database. Kaplan–Meier analysis was used to examine the effect of surgery and radiation on overall survival. We identified 394 patients with histologically-confirmed cranial chordomas. Median survival was 151 months. Most patients (89.09%) underwent surgery. Less than half (44.92%) received radiation after diagnosis. Patients who underwent surgical resection survived significantly longer than those who did not undergo resection, regardless of other treatments (151 versus 81 months, p < 0.001). Ten year survival was lower among patients receiving radiation (44.8% versus 61.4%, p = 0.66). Surgery predicted better overall survival by univariate analysis (hazard ratio [HR] 0.603, p = 0.0293); younger age at diagnosis (HR 1.028, p < 0.001), and later year of diagnosis (HR 0.971, p = 0.0027) were prognostic of improved survival in a multivariate model. In subgroup analysis of patients with documented tumor size, smaller tumor size (HR 1.021, p = 0.0067), younger age (HR 1.031, p = 0.001), and treatment within a higher volume registry (HR 0.490, p = 0.0129) predicted improved survival. Surgical intervention offers survival benefit for cranial chordomas. Findings of decreased survival in patients receiving radiation may be associated with selection. Studies examining surgical extent of resection data and radiation details are needed to determine the impact of radiotherapy.     

Pleomorphic xanthoastrocytomas: Institutional experience of 18 patients

Pleomorphic xanthoastrocytoma (PXA) is a rare, low-grade glioma (World Health Organization Grade II) that most often presents in the first two decades of life. We summarize and present our institutional experience in the management of these tumors. All patients managed for PXA at the University of California San Francisco were retrospectively identified through chart review. Patient demographics, tumor characteristics, management, and follow-up were extracted using medical records. Primary endpoints were overall (OS) and progression-free survival (PFS). In total, nineteen patients were treated for PXA from 1993–2011. Clinical data were available for analysis in 18 patients. Median OS was 209.0 months after date of surgery, with both 5 year and 10 year survival rates of 94%. In this patient cohort, tumor grade (p = 0.07), age (p = 0.32), and extent of resection (p = 0.58) did not predict OS. The majority of tumors (78%) recurred. Median PFS was 21.7 months, with 5 year and 10 year recurrence-free rates of 28% and 22%. On univariate analysis, tumor grade (p = 0.01), but not age (p = 0.51), size (p = 0.30), or extent of resection (p = 0.21), was the only covariate predictive of PFS. In patients presenting with higher tumor grade, however, earlier recurrence was demonstrated. Furthermore, the majority of recurrences (36%) occurred within the first 6 months post-operatively, which indicates the need to closely follow patients for that time.     

Patient-reported and radiographic outcomes of minimally invasive transforaminal lumbar interbody fusion for degenerative spondylolisthesis with or without reduction: A comparative study

This retrospective study aimed to compare the patient-reported outcomes and radiographic assessment of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative spondylolisthesis with reduction versus in situ fusion. Patients receiving MI-TLIF with reduction were assigned as Group A, and those without reduction were assigned as Group B. Radiographic fusion was assessed using Bridwell’s grading criteria. Preoperative and postoperative patient-reported outcomes including visual analogue score (VAS), Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA) scale and improvement rate were analyzed. There were 41 patients in Group A and 37 patients in Group B. The mean follow-up was 30.78 ± 14.15 months in Group A and 28.95 ± 10.75 months in Group B (p = 0.525). There were no significant differences in hospital stay (p = 0.261), estimated blood loss (p = 0.639), blood transfusion (p = 0.336), operation time (p = 0.762) and complications (p = 1.00) between the two groups. Radiographic fusion rate was 92.68% (38/41) in Group A, and 81.08% (30/37) in Group B (p = 0.110). Significant differences were observed in either 3-month or last follow-up JOA, VAS, and ODI compared with preoperative JOA, VAS, and ODI, respectively (p < 0.05). However, there were no significant differences in JOA, VAS, and ODI between the two groups whenever preoperatively, or 3-month postoperatively, or at the last follow-up (p > 0.05). According to MacNab criteria, the excellent and good rate was 85.37% in Group A and 86.49% in Group B (p = 0.983). MI-TLIF is an effective and satisfactory surgical technique to manage degenerative spondylolisthesis regardless of reduction or not, so routine reduction may not be a requirement in MI-TLIF for degenerative spondylolisthesis.