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Object The aim of this study was to analyze the incidence of adverse outcomes and inpatient mortality following resection of intramedullary spinal cord tumors by using the US Nationwide Inpatient Sample (NIS) database. The overall complication rate, length of the hospital stay, and the total cost of hospitalization were also analyzed from the database. Methods This is a retrospective cohort study conducted using the NIS data from 2003 to 2010. Various patient-related (demographic categories, complications, comorbidities, and median household income) and hospital-related variables (number of beds, high/low case volume, rural/urban location, region, ownership, and teaching status) were analyzed from the database. The adverse discharge disposition, in-hospital mortality, and the higher cost of hospitalization were taken as the dependent variables. Results A total of 15,545 admissions were identified from the NIS database. The mean patient age was 44.84 ± 19.49 years (mean ± SD), and 7938 (52%) of the patients were male. Regarding discharge disposition, 64.1% (n = 9917) of the patients were discharged to home or self-care, and the overall in-hospital mortality rate was 0.46% (n = 71). The mean total charges for hospitalization increased from $45,452.24 in 2003 to $76,698.96 in 2010. Elderly patients, female sex, black race, and lower income based on ZIP code were the independent predictors of other than routine (OTR) disposition (p < 0.001). Private insurance showed a protective effect against OTR disposition. Patients with a higher comorbidity index (OR 1.908, 95% CI 1.733–2.101; p < 0.001) and with complications (OR 2.214, 95% CI 1.768–2.772; p < 0.001) were more likely to have an adverse discharge disposition. Hospitals with a larger number of beds and those in the Northeast region were independent predictors of the OTR discharge disposition (p < 0.001). Admissions on weekends and nonelective admission had significant influence on the disposition (p < 0.001). Weekend and nonelective admissions were found to be independent predictors of inpatient mortality and the higher cost incurred to the hospitals (p < 0.001). High-volume and large hospitals, West region, and teaching hospitals were also the predictors of higher cost incurred to the hospitals (p < 0.001). The following variables (young patients, higher median household income, nonprivate insurance, presence of complications, and a higher comorbidity index) were significantly correlated with higher hospital charges (p < 0.001), whereas the variables young patients, nonprivate insurance, higher median household income, and higher comorbidity index independently predicted for inpatient mortality (p < 0.001). Conclusions The independent predictors of adverse discharge disposition were as follows: elderly patients, female sex, black race, lower median household income, nonprivate insurance, higher comorbidity index, presence of complications, larger hospital size, Northeast region, and weekend and nonelective admissions. The predictors of higher cost incurred to the hospitals were as follows: young patients, higher median household income, nonprivate insurance, presence of complications, higher comorbidity index, hospitals with high volume and a large number of beds, West region, teaching hospitals, and weekend and nonelective admissions.

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Purpose To pool data across multiple institutions internationally and report on the cumulative experience of brainstem stereotactic radiosurgery (SRS). Methods and Materials Data on patients with brainstem metastases treated with SRS were collected through the International Gamma Knife Research Foundation. Clinical, radiographic, and dosimetric characteristics were compared for factors prognostic for local control (LC) and overall survival (OS) using univariate and multivariate analyses. Results Of 547 patients with 596 brainstem metastases treated with SRS, treatment of 7.4% of tumors resulted in severe SRS-induced toxicity (grade ≥3, increased odds with increasing tumor volume, margin dose, and whole-brain irradiation). Local control at 12 months after SRS was 81.8% and was improved with increasing margin dose and maximum dose. Overall survival at 12 months after SRS was 32.7% and impacted by age, gender, number of metastases, tumor histology, and performance score. Conclusions Our study provides additional evidence that SRS has become an option for patients with brainstem metastases, with an excellent benefit-to-risk ratio in the hands of experienced clinicians. Prior whole-brain irradiation increases the risk of severe toxicity in brainstem metastasis patients undergoing SRS.

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OBJECTIVE Therapeutic options for brain metastases (BMs) that recur after stereotactic radiosurgery (SRS) remain limited. METHODS The authors provide the collective experience of 4 institutions where treatment of BMs that recurred after SRS was performed with stereotactic laser ablation (SLA). RESULTS Twenty-six BMs (in 23 patients) that recurred after SRS were treated with SLA (2 patients each underwent 2 SLAs for separate lesions, and a third underwent 2 serial SLAs for discrete BMs). Histological findings in the BMs treated included the following: breast (n = 6); lung (n = 6); melanoma (n = 5); colon (n = 2); ovarian (n = 1); bladder (n = 1); esophageal (n = 1); and sarcoma (n = 1). With a median follow-up duration of 141 days (range 64–794 days), 9 of the SLA-treated BMs progressed despite treatment (35%). All cases of progression occurred in BMs in which < 80% ablation was achieved, whereas no disease progression was observed in BMs in which ≥ 80% ablation was achieved. Five BMs were treated with SLA, followed 1 month later by adjuvant SRS (5 Gy daily × 5 days). No disease progression was observed in these patients despite ablation efficiency of < 80%, suggesting that adjuvant hypofractionated SRS enhances the efficacy of SLA. Of the 23 SLA-treated patients, 3 suffered transient hemiparesis (13%), 1 developed hydrocephalus requiring temporary ventricular drainage (4%), and 1 patient who underwent SLA of a 28.9-cm3 lesion suffered a neurological deficit requiring an emergency hemicraniectomy (4%). Although there is significant heterogeneity in corticosteroid treatment post-SLA, most patients underwent a 2-week taper. CONCLUSIONS Stereotactic laser ablation is an effective treatment option for BMs in which SRS fails. Ablation of ≥ 80% of BMs is associated with decreased risk of disease progression. The efficacy of SLA in this setting may be augmented by adjuvant hypofractionated SRS.

With advances in stereotactic and neuroimaging techniques, various minimally invasive image-guided techniques have gained widespread acceptance in the field of neuro-oncology. Laser interstitial thermal therapy (LITT) is an image-guided technique that involves generation of high temperatures using a laser fiber, to ablate pathological tissue. Radiation necrosis (RN) and radiosurgery resistant brain metastasis often pose significant challenges to the treating physicians. In the last two decades, various studies have documented the efficacy of LITT in managing radiosurgery resistant metastases, radiation necrosis, surgically inaccessible malignant gliomas and ablation of epileptogenic foci. The aim of this paper is to summarize the current literature on the efficacy of LITT in patients with radiation necrosis and brain metastasis. We have also touched upon the physical properties of currently available LITT systems and the mechanism of action of laser therapy including histopathological changes.