Faculty Bibliography

BACKGROUNDAND OBJECTIVE/UNASSIGNED:The authors compareocclusion rates in grade I-III AVMs in smokers and non-smokers, using propensity score matching (PSM). METHODS:The authors performed a subgroup analysis of the MISTA consortium, a multicenter registry that includes patients aged 1 to 89 years with AVMs treated between January 2010 and December 2023. Only grade I-III AVMs were included. PSM was used to control confounders. Primary endpoints included angiographic obliteration. RESULTS:A total of 353 patients with bAVMs, with a median age of 37, were included in this study: 236 were never smokers, and 117 were current or previous smokers. After 1:1 PSM of smokers and non-smokers, 33 matched pairs were obtained. The smokers were more likely to display complete obliteration at last imaging follow-up compared to non-smokers (57.6 % vs. 27.3 %;p < 0.01). The median time to last clinical(p = 0.45)and angiographic(p = 0.33)follow up was not statistically different between the two groups.There were no statistically significant differences between the two matched groups in the incidence of post-SRS edema (p = 0.23), post-treatment rupture (0 %), overall mortality (p = 0.31), and functional status at the last follow-up (p = 0.69). CONCLUSION/CONCLUSIONS:Individuals with a positive history of smoking are more likely to achieve complete obliteration of grades I-III bAVMs following SRS treatment. However, smokers do not differ from non-smokers in terms of the incidence of post-treatment rupture, overall mortality, or functional status at the last follow-up.

Leptomeningeal carcinomatosis (LC) is a severe complication of metastatic breast cancer (mBC), with rising incidence. The prognosis for patients with LC has been poor, with a median overall survival of approximately four months. However, recent therapeutic advances, in particular the introduction of trastuzumab deruxtecan have dramatically changed the landscape of CNS metastases and improved outcomes. Here, we present the case of a 42-year-old woman with recurrent HER2+ breast cancer who developed extensive LC after multiple lines of treatment. Despite progressive disease, the patient exhibited a sustained response to trastuzumab deruxtecan, a novel antibody-drug conjugate (ADC), for 15 months, which was further extended by adding tucatinib. This case underscores the potential of ADCs, like trastuzumab deruxtecan, in controlling both brain metastases and leptomeningeal disease, offering hope for prolonged survival in patients with aggressive HER2+ mBC. Additionally, we highlight the evolving role of clinical trials, molecular profiling, and interdisciplinary care in managing this challenging condition. Ongoing trials continue to investigate new therapeutic options for HER2+ mBC with CNS involvement, promising to further improve outcomes and quality of life for patients facing this devastating disease.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Arteriovenous malformations (AVMs) with perinidal aneurysms and single draining vein are associated with an elevated risk of rupture and increased procedural complexity. The role of preoperative embolization in this high-risk anatomical subset remains unclear. This study aimed to evaluate the safety and efficacy of microsurgery with preoperative embolization, compared with microsurgery alone in patients with such AVMs. METHODS:We conducted a multicenter retrospective analysis of an AVM registry from the MISTA (Multicenter International Study for Treatment of Brain AVMs) consortium and included AVMs with perinidal aneurysms and a single draining vein. Baseline characteristics, angiographic outcomes, functional outcomes, and complication rates were compared. Propensity score weighting (PSW) using the covariate balancing method was applied to adjust for baseline differences. RESULTS:Out of a total of 1919 patients, 65 met the inclusion criteria; 45 patients underwent preoperative embolization followed by microsurgery, and 20 underwent microsurgery alone. After adjustment, complete obliteration rates were similar between groups (OR 0.87, 95% CI 0.04 to 16.33, P=0.92), as were rates of functional independence at discharge and follow-up. Overall complication, symptomatic complication, and mortality rates did not differ significantly between groups. However, permanent complications were significantly lower in patients with preoperative embolization (OR 0.06, 95% CI 0.004 to 0.84, P=0.03). DISCUSSION/CONCLUSIONS:In patients with AVMs featuring perinidal aneurysms and single draining vein, preoperative embolization followed by microsurgery was associated with fewer permanent complications and no increase in adverse outcomes compared with microsurgery alone. However, given the small number of events, this finding should be interpreted cautiously.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Scholarly output is accelerating in medical domains, making it challenging to keep up with the latest neurosurgical literature. The emergence of large language models (LLMs) has facilitated rapid, high-quality text summarization. However, LLMs cannot autonomously conduct literature reviews and are prone to hallucinating source material. We devised a novel strategy that combines Reference Publication Year Spectroscopy-a bibliometric technique for identifying foundational articles within a corpus-with LLMs to automatically summarize and cite salient details from articles. We demonstrate our approach for four common spinal conditions in a proof of concept. METHODS:Reference Publication Year Spectroscopy identified seminal articles from the corpora of literature for cervical myelopathy, lumbar radiculopathy, lumbar stenosis, and adjacent segment disease. The article text was split into 1024-token chunks. Queries from three knowledge domains (surgical management, pathophysiology, and natural history) were constructed. The most relevant article chunks for each query were retrieved from a vector database using chain-of-thought prompting. LLMs automatically summarized the literature into a comprehensive narrative with fully referenced facts and statistics. Information was verified through manual review, and spine surgery faculty were surveyed for qualitative feedback. RESULTS:Our tandem approach cost less than $1 for each condition and ran within 5 minutes. Generative Pre-trained Transformer-4 was the best-performing model, with a near-perfect 97.5% citation accuracy. Surveys of spine faculty helped refine the prompting scheme to improve the cohesion and accessibility summaries. The final artificial intelligence-generated text provided high-fidelity summaries of each pathology's most clinically relevant information. CONCLUSION/CONCLUSIONS:We demonstrate the rapid, automated summarization of seminal articles for four common spinal pathologies, with a generalizable workflow implemented using consumer-grade hardware. Our tandem strategy fuses bibliometrics and artificial intelligence to bridge the gap toward fully automated knowledge distillation, obviating the need for manual literature review and article selection.

BACKGROUND:There is a paucity of data on treatment outcomes following stereotactic radiosurgery (SRS) for brain metastases from sarcoma primaries. METHODS:The International Radiosurgery Research Foundation member-sites were queried for patients with brain metastases from sarcoma primaries treated with SRS. Overall survival (OS) and local control (LC) were calculated via Kaplan-Meier analysis. Univariate analyses examined prognostic factors associated with LC and OS via log-rank t-tests and multivariate analyses (MVA) via Cox proportional hazards model. RESULTS:A total of 146 patients with 309 brain metastases were identified. Two-hundred and thirty lesions were treated with single-fraction SRS with a median dose of 20 Gy (15-24 Gy). Ninety-five patients had extracranial metastases, including 75 oligometastatic patients. One- and 2-year OS and LC rates were 47.7% and 37.3%, and 78.3% and 62.2%, respectively. On univariate analyses, superior 1-year OS was noted among leiomyosarcomas (69.7% vs. 42.6%; p = .02) with poorer outcomes among pleomorphic histologies (10.5% vs. 50.7%; p = .002). Pleomorphic histologies were associated with poorer OS on MVA (hazard ratio [HR], 3.13; p = .006). On MVA, LC was inferior among patients of age ≥45 years (HR, 3.78; p < .001) and superior among leiomyosarcomas (HR, 0.31; p = .03). OS was prognosticated based on adverse factors (ie, nonleiomyosarcoma histology and progressive extracranial metastases). Two-year OS for patients with and without adverse features were 78.6% and 31.5%, respectively. CONCLUSIONS:LC outcomes were driven by histology and age with superior LC among leiomyosarcomas and patients of age <45 years. OS was driven by nonleiomyosarcoma histology and the presence of progressive extracranial disease.

BACKGROUND:Given the low haemorrhagic risk of intracranial low-grade dural arteriovenous fistulas (dAVFs), the benefits of routine intervention remain controversial. This study compares patient outcomes treated with stereotactic radiosurgery (SRS) versus conservative management. METHOD/METHODS:Multicentre retrospective analysis of the Consortium for Dural Arteriovenous Fistula Outcomes Research and the International Radiosurgery Research Foundation data. Inclusion criteria were (1) intracranial low-grade dAVF diagnosed by catheter-based angiography, (2) no prior dAVF-related haemorrhage and (3) management with upfront SRS (intervention group) or conservative management (observation group). The primary outcome was symptomatic improvement. Secondary outcomes included dAVF obliteration, up-conversion, haemorrhage, improvement and favourable modified Rankin Scale (mRS) at follow-up. RESULTS:304 patients with a mean age of 56 years (SD 13.5) and a follow-up of 46.7 months (SD 45.5) were included. 135 (44.4%) were managed conservatively and 169 (55.6%) had upfront SRS. Compared with the observation group, symptomatic and mRS Score improvement (≥1-point decrease in baseline score) was more likely in the intervention group (95.1% vs 58.5%; OR=13.75 (5.61-33.69) and 37.0% vs 24.0%; OR=1.85 (1.09-3.15), respectively). These findings remained significant after multiple imputation and propensity score matching. Remaining outcomes were similar between groups. The all-cause mortality rate was 5.4% (n=16), unrelated to the dAVF or treatment. Five (3.0%) SRS-related complications were reported and resolved during the follow-up period. CONCLUSIONS:SRS was associated with increased symptomatic and mRS Score improvement for low-grade dAVFs compared with conservative management. SRS had a low complication risk and did not appear to alter dAVF obliteration or haemorrhage. Future prospective trials on SRS as a first-line intervention for symptomatic low-grade dAVFs should be considered.

BACKGROUND:Pituitary metastases (PM) account for 0.4% of all intracranial metastases and typically present with visual and endocrinological deficits. Stereotactic radiosurgery (SRS) has shown excellent tumor control and safety profile in the management of intracranial metastases. However, its role and safety in managing metastases to the pituitary gland are not well-characterized. This study aims to evaluate SRS outcomes and safety profile in the management of PM in a multicenter international cohort. METHODS:The authors retrospectively analyzed data from 63 patients with PM treated with SRS across 12 institutions, assessing clinical and radiological outcomes, including survival rates, tumor control, visual and endocrinological outcomes, and post-treatment complications. RESULTS:Among 63 patients included in the study (median tumor volume: 1.5 cc), SRS demonstrated a local tumor control rate of 93.1% at 12 months. The median survival was 25.4 months and overall survival rates of 77.6%, 65.9%, and 55.1% at 6, 12, and 18 months, respectively. In multivariate analysis, a margin dose for PM > 10 Gy emerged as an independent predictor across progression-free survival (HR: 0.20, p < 0.01), distant metastasis-free survival (HR: 0.30, p = 0.01), and overall survival. (HR: 0.15, p < 0.01). Following SRS, most patients showed stable or improved visual function (n = 17/18). A small percentage of patients experienced complications: developed new visual deficits (n = 1/63), experienced new anterior pituitary hormone deficiency (n = 5/63), and developed arginine vasopressin (AVP)-deficiency post-treatment (n = 2/63). CONCLUSION/CONCLUSIONS:SRS is an important modality in the management of PM, offering excellent local tumor control and survival outcomes with minimal morbidity. These findings support the incorporation of SRS into the multidisciplinary management for treating patients with PM.