Neurosurgery
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Review
Strategies to Mitigate Toxicities From Stereotactic Body Radiation Therapy for Spine Metastases.
Improvements in systemic therapy are translating into more patients living longer with metastatic disease. Bone is the most common site of metastasis, where spinal lesions can result in significant pain impacting quality of life and possible neurological dysfunction resulting in a decline in performance status. ⋯ In our review, we provide an in-depth review and expert commentary regarding seminal literature that defined clinically meaningful toxicity endpoints with actionable dosimetric limits and/or clinical management strategies to mitigate toxicity potentially attributable to SBRT of the spine. We placed a spotlight on radiation myelopathy (de novo, reirradiation after conventional external beam radiation therapy or salvage after an initial course of spinal SBRT), plexopathy, vertebral compression fracture, pain flare, esophageal toxicity, myositis, and safety regarding combination with concurrent targeted or immune therapies.
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Clinical Trial
Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Series of 60 Cases.
Chronic subdural hematoma (SDH) is a particularly challenging pathology due to high recurrence rates (2%-37%) and complex medical comorbidities that tend to afflict the patient population. Recently, there have been several case series published describing the use of middle meningeal artery (MMA) embolization as an alternative to surgery for treatment of new or recurrent chronic SDH. ⋯ MMA embolization may represent a minimally-invasive alternative to surgery for new or recurrent chronic SDH, or as prophylaxis to reduce the risk of recurrence after surgery. Given our encouraging results with a 91% long-term success rate, a large scale clinical trial is warranted.
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Fractionated stereotactic radiosurgery (SRS) for vestibular schwannomas (VS) has been theorized to allow for tumor control with higher rates of hearing preservation in selected patients with useful hearing. However, there is a paucity of literature with formal audiologic measures of hearing preservation to support the standard use of fractionated SRS in VS. We hypothesized that fractionation would diminish the amount of hearing damage. ⋯ This retrospective analysis supports the use of fractionated SRS to preserve hearing in patients with VS. SAT can be used as an objective metric of hearing response to radiosurgery.
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Limited data exist on the safety of overlapping surgery, a practice that has recently received widespread attention. ⋯ Overlapping neurosurgery is associated with noninferior patient outcomes that may be driven by surgeon selection of healthier patients, regardless of specific overlap timing.
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Gamma Knife radiosurgery (GKRS; Elekta AB) remains a well-established treatment modality for vestibular schwannomas. Despite highly effective tumor control, further research is needed toward optimizing long-term functional outcomes. Whereas dose-rate effects may impact post-treatment toxicities given tissue dose-response relationships, potential effects remain largely unexplored. ⋯ Whereas GKRS provides excellent tumor control and effective symptomatic relief for vestibular schwannomas, dose-rate effects may impact post-treatment functional outcomes. Further research remains warranted.