Moussalem, Charbel K.

BACKGROUND AND OBJECTIVES: Access to the amygdala and hippocampus (A/H) is complex. To address the limitations and invasiveness of traditional approaches, including the Transsylvian, Subtemporal, and Supracerebellar infratentorial approaches, we developed the suprapetrous infratemporal (SPIT) approach. This study describes the nuances of this approach in both cadaveric studies and clinical cases. METHODS: Three unilateral exposures were performed using microscopic and endoscopic methodologies in the SPIT approach. After cadaveric investigation, this approach was successfully implemented in representative clinical cases. RESULTS: The SPIT approach enabled direct access to the inferior A/H, circumventing the requirement for temporal lobe retraction and detachment of the temporal lobe from the dura through a subtemporal route by drilling the upper part of the mastoid, consequently mitigating tension on the vein of Labbé. This enabled a bottom-up view because one would gain with a zygomatic osteotomy and forward projection like a mini-posterior petrosal view by using a transmastoid view, without cutting down the zygomatic arch and opening the dura subtemporally, limiting patient pain and preventing case comorbidity. The SPIT approach was performed in 2 cases of mesial temporal cavernoma presenting with seizures. The lesion was visualized intraoperatively and was successfully removed in these cases. The postoperative course was excellent with no complications, and gross total resection was radiographically confirmed with Engel Class 1a seizure freedom. CONCLUSION: The SPIT approach is a complementary approach for inferior A/H disease, combining the combined middle fossa approach modified for intradural pathology. Limited drilling of the upper aspect of the mastoid with a medial dural opening at the level of the arcuate eminence provides a direct trajectory with minimal brain retraction. Additional research encompassing a larger patient cohort and extended follow-up periods is required to substantiate the advantages of SPIT in the management of inferior A/H lesions.

OBJECTIVE Chordomas are rare tumors of the skull base and spine believed to arise from the vestiges of the embryonic notochord. These tumors are locally aggressive and frequently recur following resection and adjuvant radiotherapy. Proton therapy has been introduced as a tissue-sparing option because of the higher level of precision that proton-beam techniques offer compared with traditional photon radiotherapy. This study aimed to compare recurrence in patients with chordomas receiving proton versus photon radiotherapy following resection by applying tree-based machine learning models. METHODS The clinical records of all patients treated with resection followed by adjuvant proton or photon radiotherapy for chordoma at Mayo Clinic were reviewed. Patient demographics, type of surgery and radiotherapy, tumor recurrence, and other variables were extracted. Decision tree classifiers were trained and tested to predict long-term recurrence based on unseen data using an 80/20 split. RESULTS Fifty-three patients with a mean ± SD age of 55.2 ± 13.4 years receiving surgery and adjuvant proton or photon therapy to treat chordoma were identified; most patients were male. Gross-total resection was achieved in 54.7% of cases. Proton therapy was the most common adjuvant radiotherapy (84.9%), followed by conventional or external-beam radiation therapy (9.4%) and stereotactic radiosurgery (5.7%). Patients receiving proton therapy exhibited a 40% likelihood of having recurrence, significantly lower than the 88% likelihood observed in those treated with nonproton therapy. This was confirmed on logistic regression analysis adjusted for extent of tumor resection and tumor location, which revealed that proton adjuvant radiotherapy was associated with a decreased risk of recurrence (OR 0.1, 95% CI 0.01–0.71; p = 0.047) compared with photon therapy. The decision tree algorithm predicted recurrence with an accuracy of 90% (95% CI 55.5%–99.8%), with the lowest risk of recurrence observed in patients receiving gross-total resection with adjuvant proton therapy (23%). CONCLUSIONS Following resection, adjuvant proton therapy was associated with a lower risk of chordoma recurrence compared with photon therapy. The described machine learning models were able to predict tumor progression based on the extent of tumor resection and adjuvant radiotherapy modality used.

Introduction Background: The Woven Endo‐Bridge (WEB) device is an intrasaccular device being used to secure intracranial aneurysms through the endovascular approach. The WEB is commonly used for wide‐neck aneurysms. There are no comprehensive studies to assess the low‐profile device WEB 17 so far. Although, some single studies have reported their early experience using the device. We plan to provide a comprehensive assessment of the early center experience using the WEB 17 device to secure intracranial aneurysms. Objective: To provide an overview of the early‐center experience of the 0.017‐inch endovascular Woven EndoBridge device (WEB‐17) device. Methods A systematic review and meta‐analysis were conducted following the PRISMA recommendations. On April 15, 2023, we searched for eligible papers in Pubmed, Web of Science (ISI), Scopus, and Embase databases. The meta‐analysis was done using R software version 4.3.0. and the "meta" package. Pooled prevalence (%) and their corresponding 95% confidence intervals (CI), random‐effects model based and the generalized linear mixed models (GLMMs) method. On the presence of multiple follow‐up points, we included the last available in the analysis. Complete occlusion was defined as Raymond–Roy occlusion classification (RROC) class I, and adequate occlusion was defined as RROC class I or II. Results Seven studies were finally included following the double‐reviewer screening of the retrieved literature. The patients' mean age ranged from 52.5±13.8 to 62.0±9.5 years, and 71.0% were females. The mean follow‐up duration ranged from 6±2.25 months to 11.6±4. Technical success was achieved in 98.34% (95% CI= 96.72‐99.17) of the cases, while adjunctive devices were used in 4.97% (95% CI= 1.60‐14.39) of them (Figure 1). The complete occlusion rate was 72.54% (95% CI= 63.44‐80.08) (Figure 2), while the adequate occlusion rate was 94.41 (95% CI= 88.17‐97.46) (Figure 3). There was no significant heterogeneity in all pooled outcomes. Conclusion The early experience of the device shows an efficacy profile comparable with the currently available devices in treating intracranial aneurysms.

Background The Woven Endo-Bridge (WEB) device revolutionized the treatment of wide-necked bifurcation aneurysms by intrasaccular flow diversion. The latest advancement is the WEB-17 system, offering greater flexibility with fewer wires, enabling treatment of smaller distal aneurysms using smaller microcatheters than the WEB-21 system. Methods We conducted a systematic review following preferred reporting items for systematic reviews and meta-analyses guidelines, analyzing data from seven retrospective cohort studies involving 483 aneurysms treated with the WEB-17 device. Statistical analysis computed pooled prevalence rates and 95% confidence intervals using appropriate models for each outcome and R software version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria). Results Technical success was achieved in 475 out of 483 aneurysms treated with the WEB-17 device, with a success rate of 98.34% (95% confidence interval (CI) = 96.72–99.17). Among the successful cases, 4.97% (95% CI = 1.60–14.39) required adjunctive devices. Adequate occlusion, defined as complete occlusion or neck remnants, was observed in 94.41% (95% CI = 88.17–97.46) of cases. Periprocedural complications were infrequent, with thromboembolic complications occurring in 4.93% (95% CI = 3.29–7.30) of cases, hemorrhagic complications in 1.28% (95% CI = 0.58–2.83), and postprocedural neurologic complications in 0.99% (95% CI = 0.31–3.14). Procedure-related morbidity was observed in 1.71% (95% CI = 0.86–3.39) of cases, and there was one procedure-related mortality reported at 0.21% (95% CI = .03–1.50). Mortality unrelated to the procedure occurred in 1% (95% CI = 0.23–4.15). Conclusion Our findings suggest that the WEB-17 device is associated with a high rate of technical success, favorable angiographic outcomes, and a low rate of periprocedural complications. Further research, including prospective trials, is needed to confirm these findings and establish its safety and efficacy definitively.