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Objective Cystic vestibular schwannomas (CVSs) are anecdotally believed to have worse clinical and tumor-control outcomes than solid vestibular schwannomas (SVSs); however, no data have been reported to support this belief. In this study, we characterize the clinical outcomes of patients with CVSs versus those with SVSs. Design This is a retrospective review of prospectively collected data. Setting This study is set at single high-volume neurosurgical institute. Participants We queried a database for details on all patients diagnosed with vestibular schwannomas between January 2009 and January 2014. Main Outcome Measures Records were retrospectively reviewed and analyzed using univariate and multivariate analyses to study the differences in clinical outcomes and tumor progression or recurrence. Results Of a total of 112 tumors, 24% (n = 27) were CVSs and 76% (n = 85) were SVSs. Univariate analysis identified the extent of resection, Koos grade, and tumor diameter as significant predictors of recurrence (p ≤ 0.005). However, tumor diameter was the only significant predictor of recurrence in the multivariate analysis (p = 0.007). Cystic change was not a predictor of recurrence in the univariate or multivariate analysis (p ≥ 0.40). Postoperative facial nerve and hearing outcomes were similar for both CVSs and SVSs (p ≥ 0.47). Conclusion Postoperative facial nerve outcome, hearing, tumor progression, and recurrence are similar for patients with CVSs and SVSs. As CVS growth patterns and responses to radiation are unpredictable, we favor microsurgical resection over radiosurgery as the initial treatment. Our data do not support the commonly held belief that cystic tumors behave more aggressively than solid tumors or are associated with increased postoperative facial nerve deficits.

To evaluate surgical resection with brachytherapy placement as a salvage treatment in patients with recurrent high-grade meningioma who exhausted prior external beam treatment options. Single-center retrospective review of our institutional experience of brachytherapy implantation from 2012 to 2018. The primary outcome of the study was progression free survival (PFS). Secondary outcomes included overall survival (OS) and complications. A matched cohort of patients not treated with brachytherapy over the same time period was evaluated as a control group. All patients had received prior radiation treatment and underwent planned gross total resection (GTR) surgery. A total of 27 cases were evaluated. Compared with prior treatment, brachytherapy implantation demonstrated a statistically significant improvement in tumor control [HR 0.316 (0.101 − 0.991), p = 0.034]. PFS-6 and PFS-12 were 92.3% and 84.6%, respectively. Compared with the matched control cohort, brachytherapy treatment demonstrated improved PFS [HR 0.310 (0.103 − 0.933), p = 0.030]. Overall survival was not statistically significantly different between groups [HR 0.381 (0.073 − 1.982), p = 0.227]. Overall postoperative complications were comparable between groups, although there was a higher incidence of radiation necrosis in the brachytherapy cohort. Brachytherapy with planned GTR improved PFS in recurrent high-grade meningioma patients who exhausted prior external beam radiation treatment options. Future improvement of brachytherapy dose delivery methods and techniques may continue to prolong control rates and improve outcomes for this challenging group of patients.

Objectives This study aimed at evaluating facial nerve outcomes in vestibular schwannoma patients presenting with preoperative facial nerve palsy. Design A retrospective review. Setting Single-institution cohort. Participants Overall, 368 consecutive patients underwent vestibular schwannoma resection. Patients with prior microsurgery or radiosurgery were excluded. Main Outcome Measures Incidence, House–Brackmann grade. Results Of 368 patients, 9 had confirmed preoperative facial nerve dysfunction not caused by prior treatment, for an estimated incidence of 2.4%. Seven of these nine patients had Koos grade 4 tumors. Mean tumor diameter was 3.0 cm (range: 2.1–4.4 cm), and seven of nine tumors were subtotally resected. All nine patients were followed up clinically for ≥ 6 months. Of the six patients with a preoperative House–Brackmann grade of II, two improved to grade I, three were stable, and one patient worsened to grade III. Of the three patients with grade III or worse, all remained stable at last follow-up. Conclusions Preoperative facial nerve palsy is rare in patients with vestibular schwannoma; it tends to occur in patients with relatively large lesions. Detailed long-term outcomes of facial nerve function after microsurgical resection for these patients have not been reported previously. We followed nine patients and found that eight (89%) of the nine patients had either stable or improved facial nerve outcomes after treatment. Management strategies varied for these patients, including rates of subtotal versus gross-total resection and the use of stereotactic radiosurgery in patients with residual tumor. These results can be used to help counsel patients preoperatively on expected outcomes of facial nerve function after treatment.

Objectives The Hardy classification is used to classify pituitary tumors for clinical and research purposes. The scale was developed using lateral skull radiographs and encephalograms, and its reliability has not been evaluated in the magnetic resonance imaging (MRI) era. Design Fifty preoperative MRI scans of biopsy-proven pituitary adenomas using the sellar invasion and suprasellar extension components of the Hardy scale were reviewed. Setting This study was a cohort study set at a single institution. Participants There were six independent raters. Main Outcome Measures The main outcome measures of this study were interrater reliability, intrarater reliability, and percent agreement. Results Overall interrater reliability of both Hardy subscales on MRI was strong. However, reliability of the intermediate scores was weak, and percent agreement among raters was poor (12–16%) using the full scales. Dichotomizing the scale into clinically useful groups maintained strong interrater reliability for the sellar invasion scale and increased the percent agreement for both scales. Conclusion This study raises important questions about the reliability of the original Hardy classification. Editing the measure to a clinically relevant dichotomous scale simplifies the rating process and may be useful for preoperative tumor characterization in the MRI era. Future research studies should use the dichotomized Hardy scale (sellar invasion Grades 0–III versus Grade IV, suprasellar extension Types 0–C versus Type D).

BACKGROUND Three-dimensional (3D) printing holds great potential for lateral skull base surgical training; however, studies evaluating the use of 3D-printed models for simulating transtemporal approaches are lacking. OBJECTIVE To develop and evaluate a 3D-printed model that accurately represents the anatomic relationships, surgical corridor, and surgical working angles achieved with increasingly aggressive temporal bone resection in lateral skull base approaches. METHODS Cadaveric temporal bones underwent thin-slice computerized tomography, and key anatomic landmarks were segmented using 3D imaging software. Corresponding 3D-printed temporal bone models were created, and 4 stages of increasingly aggressive transtemporal approaches were performed (40 total approaches). The surgical exposure and working corridor were analyzed quantitatively, and measures of face validity, content validity, and construct validity in a cohort of 14 participants were assessed. RESULTS Stereotactic measurements of the surgical angle of approach to the mid-clivus, residual bone angle, and 3D-scanned infill volume demonstrated comparable changes in both the 3D temporal bone models and cadaveric specimens based on the increasing stages of transtemporal approaches (PANOVA

Introduction Nationwide databases are frequently used resources for assessing practice patterns and clinical outcomes. However, analyses based on billing codes may be limited by the inconsistent application of current procedural terminology (CPT) codes to specific operations. We investigated the variability among commonly used CPT codes for vestibular schwannomas resection and sought to identify factors that underlie this variation. Methods The surgical procedure for 274 cases of vestibular schwannoma resections from two institutions was reviewed and classified as retrosigmoid, translabyrinthine, or middle fossa approaches. We then assessed the CPT codes assigned to each case and analyzed their association with surgical approach, surgeons involved, the coding specialty, and year of surgery. We further compared the incidence of CPT codes assigned for vestibular schwannoma surgeries in the American College Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2014. Results The majority (65%) of vestibular schwannoma resections within the institutional cohort were billed with skull base approach and/or excision codes, whereas 76% of cases in NSQIP were associated with a single craniotomy for tumor code. The use of skull base codes over the past decade increased within our institutional cohort but remained relatively stable within NSQIP. CPT codes did not consistently reflect the operative approaches for vestibular schwannomas. Conclusion We observed significant variability in coding patterns for vestibular schwannoma surgeries within institutions, surgical practices, and national databases. These results call for discretion in interpretation of data from aggregated billing code-based nationwide databases and suggests a role for institutional standardization of CPT assignments for the same approaches.