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Tumor volume improves preoperative differentiation of prolactinomas and nonfunctioning pituitary adenomas

Wright, Kyla; Lee, Matthew; Escobar, Natalie; Pacione, Donato; Young, Matthew; Fatterpekar, Girish; Agrawal, Nidhi
PURPOSE/OBJECTIVE:Both prolactinomas and nonfunctioning adenomas (NFAs) can present with hyperprolactinemia. Distinguishing them is critical because prolactinomas are effectively managed with dopamine agonists, whereas compressive NFAs are treated surgically. Current guidelines rely only on serum prolactin (PRL) levels, which are neither sensitive nor specific enough. Recent studies suggest that accounting for tumor volume may improve diagnosis. The objective of this study is to investigate the diagnostic utility of PRL, tumor volume, and imaging features in differentiating prolactinoma and NFA. METHODS:Adult patients with pathologically confirmed prolactinoma (n = 21) or NFA with hyperprolactinemia (n = 58) between 2013 and 2020 were retrospectively identified. Diagnostic performance of clinical and imaging variables was analyzed using receiver-operating characteristic curves to calculate area under the curve (AUC). RESULTS:with sensitivity of 100% and specificity of 82.76%. Binary logistic regression found that PRL was a significant positive predictor of prolactinoma diagnosis, whereas tumor volume, presence of CSI not previously defined, and T2 hyperintensity were significant negative predictors. The regression model had an AUC of 0.9915 (p < 0.0001). CONCLUSIONS:Consideration of tumor volume improves differentiation between prolactinomas and NFAs, which in turn leads to effective management.
PMID: 33966173
ISSN: 1559-0100
CID: 4878192

Simultaneous Multislice for Accelerating Diffusion MRI in Clinical Neuroradiology Protocols

Hoch, M J; Bruno, M; Pacione, D; Lui, Y W; Fieremans, E; Shepherd, T M
BACKGROUND AND PURPOSE/OBJECTIVE:Diffusion MR imaging sequences essential for clinical neuroradiology imaging protocols may be accelerated with simultaneous multislice acquisitions. We tested whether simultaneous multislice-accelerated diffusion data were clinically equivalent to standard acquisitions. MATERIALS AND METHODS/METHODS:; 60 directions). The corticospinal tract and arcuate fasciculus ipsilateral to the lesion were generated using the same ROIs and then blindly assessed by a neurosurgeon for anatomic fidelity, perceived quality, and impact on surgical management. Tract volumes were compared for spatial overlap. RESULTS:Two-slice simultaneous multislice diffusion reduced acquisition times from 141 to 45 seconds for routine diffusion and from 7.5 to 5.9 minutes for diffusion tractography using 3T MR imaging. The simultaneous multislice-accelerated diffusion sequence was rated equivalent for diagnostic utility despite reductions to perceived image quality. Simultaneous multislice-accelerated diffusion tractography was rated clinically equivalent. Dice similarity coefficients between routine and simultaneous multislice-generated corticospinal tract and arcuate fasciculus tract volumes were 0.78 (SD, 0.03) and 0.71 (SD, 0.05), respectively. CONCLUSIONS:-space-resolution diffusion acquisitions required for translating advanced diffusion models into clinical practice.
PMID: 33985946
ISSN: 1936-959x
CID: 4868222

Determinants of surgical remission in prolactinomas: a systematic review and meta-analysis

Wright, Kyla; Chaker, Layal; Pacione, Donato; Sam, Keren; Feelders, Richard; Xia, Yuhe; Agrawal, Nidhi
OBJECTIVE:Prolactin secreting tumors respond well to medical management with a small fraction of patients requiring surgery. We conducted a systematic review and meta-analysis to study the determinants of surgical remission in these tumors. METHODS:We searched PubMed to identify eligible studies reporting postoperative remission in patients treated with transsphenoidal surgery for prolactinoma. Primary outcomes included postoperative remission, follow-up remission, and recurrence. Postoperative and follow-up remission were defined as normoprolactinemia at less than and greater than one-year post-operation respectively. Recurrence was defined as hyperprolactinemia after initial normalization of prolactin levels. Odds ratios (OR) were calculated, stratified by radiological size, tumor extension, and tumor invasion, and analyzed using a random-effects model meta-analysis. RESULTS:Thirty-five studies were included. Macroadenomas were associated with lower rates of postoperative remission OR 0.20, 95% confidence interval [CI] 0.16-0.24) and lower rates of remission at follow-up (OR 0.11, 95% CI 0.053-0.22). Postoperative remission was less likely in tumors with extra- or suprasellar extension (OR 0.16, 95% CI 0.06-0.43) and tumors with cavernous sinus invasion (OR 0.03, 95% CI 0.01-0.13). Female gender and absence of preoperative dopamine agonist (DA) treatment were also associated with higher remission rates. Across the included studies, there was considerable heterogeneity in each primary outcome (postoperative remission I2=94%, follow-up remission I2=86%, recurrence I2=68%). CONCLUSIONS:Transsphenoidal surgery for prolactinomas may be particularly effective in small, non-invasive, treatment naive tumors and may provide a viable first-line alternative to dopamine agonist therapy in such patients.
PMID: 34325023
ISSN: 1878-8769
CID: 4955402

Correction to: Tumor volume improves preoperative differentiation of prolactinomas and nonfunctioning pituitary adenomas

Wright, Kyla; Lee, Matthew; Escobar, Natalie; Pacione, Donato; Young, Matthew; Fatterpekar, Girish; Agrawal, Nidhi
PMID: 34097197
ISSN: 1559-0100
CID: 4906032

Meningitis in the Setting of Frontoethmoidal and Temporal Meningoencephaloceles

Kumar, Arooshi; Shah, Jugal; Melmed, Kara; Pacione, Donato; Lieberman, Seth; Lewis, Ariane
This is a patient with multiple meningoencephaloceles which resulted in bacterial meningitis and subsequent status epilepticus. We identify impressive imaging findings demonstrating herniation of the meninges from nasal and bitemporal skull base defects possibly as a result of intracranial hypertension.
PMID: 33791067
ISSN: 1941-8744
CID: 4852032

Skull Base Aerosol Generating Cases Amidst the COVID-19 Pandemic: An Experience from the Epicenter

Dastagirzada, Yosef; Klauberg, Olga; Sheerin, Kathleen; Lieberman, Seth; Lebowitz, Richard; McMenomey, Sean; Sen, Chandranath; Roland, J. Thomas; Golfinos, John G.; Pacione, Donato
Soon after the World Health Organization declared the severe acute respiratory syndrome coronavirus 2 a global health emergency on January 30, 2020, New York City was plagued by the virus and its health system and economy pushed to their limits. The majority of the limited neurosurgical data in relation to COVID-19 is anecdotal and the higher theoretical risk of transmission of the virus among skull base aerosol generating (SBAG) cases has not been investigated or discussed in a neurosurgical population. We discuss a series of 13 patients who underwent 15 SBAG surgical procedures during the peak of COVID-19 in our hospital system and the protocols use perioperatively for their procedures. Our data support that with proper preoperative testing, a well-delineated surgical algorithm, and appropriate personal protective equipment, emergent/urgent cases can be done safely in hospitals that are currently experiencing high volumes of COVID-19 cases as we did in March to May of 2020.
ISSN: 2193-634x
CID: 4832592

Correction: Tumor volume improves preoperative differentiation of prolactinomas and nonfunctioning pituitary adenomas (Endocrine, (2021), 10.1007/s12020-021-02744-8)

Wright, Kyla; Lee, Matthew; Escobar, Natalie; Pacione, Donato; Young, Matthew; Fatterpekar, Girish; Agrawal, Nidhi
In this erratum the * sign has been included for the following authors Kyla Wright and Matthew Lee to indicate the first co-authors. In the abstract the CSI has been defined to "cavernous sinus invasion".The Original article has been updated.
ISSN: 1355-008x
CID: 4963422

Venous Duplex Ultrasound Surveillance in the Neurosurgical Population: A Single-Center Quality Improvement Initiative

Rozman, Peter A; Kurland, David B; Golub, Danielle; Trang, Myra; Rothstein, Aaron; Lewis, Ariane; Pacione, Donato
BACKGROUND:Venous thromboembolism (VTE) represents a significant source of morbidity and mortality in the inpatient population and is considered a leading preventable cause of death among inpatients. Neurosurgical inpatients are of particular interest because of the greater rates of immobility, steroid use, and potential consequences of postoperative hemorrhage. A consensus protocol for VTE screening in this population has not yet been developed, and institutional protocols vary widely. METHODS:We performed a retrospective review of lower extremity venous duplex ultrasonography (VDUS) usage at our institution and applied this information to the development of a neurosurgery department protocol, with consideration of high-risk patient risk factors and indications for VDUS ordering. We then implemented this protocol, which consisted of preoperative screening of patients at high risk of VTE and limited postoperative surveillance, for a 6-month period and compared VDUS usage and VTE occurrence. RESULTS:Preoperative VDUS screening before nonemergent neurosurgical procedures in high-risk patients with active cancer, an inability to ambulate, or a history of deep vein thrombosis (DVT) identified proximal DVTs that were then treated. Postoperative routine surveillance VDUS scans only diagnosed incidental isolated calf DVT for which no clinically relevant sequelae occurred. Overall, postoperative surveillance VDUS usage decreased significantly (66.9% vs. 13.5%; P = 0.001). CONCLUSIONS:Our findings lend support to preoperative screening of high-risk patients and suggest that routine postoperative VDUS surveillance of asymptomatic patients is unnecessary.
PMID: 32758655
ISSN: 1878-8769
CID: 4614312

Benefits of the Subdural Evacuating Port System (SEPS) Procedure Over Traditional Craniotomy for Subdural Hematoma Evacuation

Golub, Danielle; Ashayeri, Kimberly; Dogra, Siddhant; Lewis, Ariane; Pacione, Donato
Background/UNASSIGNED:There remains no consensus on the optimal primary intervention for subdural hematoma (SDH). Although historically favored, craniotomy carries substantial morbidity and incurs significant costs. Contrastingly, the subdural evacuating port system (SEPS) is a minimally invasive bedside procedure. We assessed the benefits of SEPS over traditional craniotomy for SDH evacuation. Methods/UNASSIGNED:A single-center retrospective cohort study of SDH patients receiving craniotomy or SEPS between 2012 and 2017 was performed. Information regarding demographics, medical history, presentation, surgical outcomes, cost, and complications was collected. Pre- and postoperative hematoma volumes were calculated using 3D image segmentation using Vitrea software. Multivariate regression models were employed to assess the influence of intervention choice. Results/UNASSIGNED:= 1.000). Conclusion/UNASSIGNED:In this retrospective cohort, SEPS was noninferior to craniotomy at reducing SDH hematoma volume. The SEPS procedure was also associated with decreased length of stay hospitalization costs, and postoperative seizures and demonstrated a comparable recurrence rate to craniotomy for chronic SDH in particular.
PMID: 32983343
ISSN: 1941-8744
CID: 4615802

Transclival Approach for Resection of a Pontine Cavernous Malformation: 2-Dimensional Operative Video

London, Dennis; Lieberman, Seth; Tanweer, Omar; Pacione, Donato
Cerebral cavernous malformations are common vascular anomalies consisting of a cluster of capillaries without intervening brain tissue.1 A variety of approaches for resection have been undertaken,2 and a handful of case reports have described the endoscopic, endonasal, transclival approach.3 We present a case of a 51-yr-old woman with lupus and hepatitis B-associated cirrhosis who presented with diplopia, dysphagia, and ataxia. She had a left abducens nerve palsy and magnetic resonance imaging (MRI) showed a left pontine cavernous malformation. After a repeat hemorrhage, she consented to surgical resection. The lesion appeared to come to the medial pontine pial surface. Tractography indicated a rightward displacement of the left corticospinal tract. Therefore, an endoscopic, transnasal, transclival approach was chosen. A lumbar drain was placed preoperatively. The clivus and ventral petrous bone were drilled using the vidian canal to help identify the anterior genu of the petrous carotid artery. The clival dura was opened, revealing the abducens nerve exiting the ventral pons. The cavernoma was visible on the surface lateral to the nerve. It was removed using blunt dissection and the remaining cavity inspected. The skull base was reconstructed using an abdominal dermal-fat graft and Alloderm covered by a nasoseptal flap. Postoperatively she had transient swallowing difficulty. The lumbar drain was kept open for 5 d. Cerebrospinal fluid (CSF) leak was ruled out using an intrathecal fluorescein injection. She was discharged home, but presented 2 wk postoperatively with aseptic meningitis, which was treated supportively. Postoperative imaging did not show residual cavernoma.
PMID: 32047906
ISSN: 2332-4260
CID: 4304372