Justin Meinert

OBJECTIVE: Frailty, a state of increased vulnerability to adverse health outcomes, is associated with poor neurosurgical outcomes. The relationship between frailty and stereotactic radiosurgery (SRS) for brain metastases (BMs), however, has not been adequately described. In this study, the authors attempted to examine the connection between frailty and outcomes for patients receiving SRS for BMs. METHODS: A single-center retrospective cohort study was performed. The 5-factor modified frailty index (mFI-5) was used to stratify patients into pre-frail (mFI-5 score 0-1), frail (mFI-5 score 2), and severely frail (mFI-5 score ≥ 3) cohorts at the time of SRS treatment. Both overall survival (OS) and progression-free survival (PFS) were evaluated. Factors associated with OS/PFS were assessed using Kaplan-Meier analysis and a Cox proportional hazards model. RESULTS: Two hundred three patients met the inclusion criteria and received SRS to one or more BMs. Fifty-six patients (27.6%) received SRS as an adjuvant treatment. The 12-month OS and PFS rates were 58.6% and 45.5%, respectively. One hundred twenty-six patients (62.1%) were classified as pre-frail, 58 (28.6%) as frail, and 19 (9.4%) as severely frail. Significantly less OS was demonstrated in frailer groups (frail hazard ratio [HR] 3.14, p < 0.005; severely frail HR 3.13, p < 0.005). Compared with pre-frail patients, frail patients had shorter intervals of PFS (frail HR 2.05, p < 0.005). Five patients (2.5%) had symptomatic radiation necrosis (RN) and 60 (29.6%) required repeat radiation. CONCLUSIONS: Higher frailty scores at the time of SRS treatment were predictive of shorter OS and PFS intervals.

Meinert, Justin BPhil; Shah, Sanjit MD; Kaye, Joel MD; Doyle, Edward MD; Samy, Ravi MD; Horne, Dale MD; Forbes, Jonathan A. MD Author Information

Intro: Perioperative stroke is a known but severe neurological complication that can occur after carotid endarterectomy (CEA). Perioperative stroke has been shown to increase the risk of morbidity and mortality in the short and long term. Intraoperative neurophysiological monitoring with somatosensory evoked potentials (SSEPs) is utilized to warn the surgical team of impending neurological deficits. Our goal for this study is to quantitatively evaluate the diagnostic value of SSEP changes in predicting perioperative stroke during CEA. Method: We identified all perioperative strokes during the hospital stay. We further classified them into major and minor strokes. To quantitatively assess SSEP changes, amplitudes and latencies of the cortical SSEP responses were measured during various critical and consistent times during CEA. Results: There is a significant difference in amplitude between controls and perioperative strokes at all time points after pre-incision, not including the end of the surgery. Patients with perioperative strokes had significantly decreased amplitude from all four baselines. The area under the curve for ROC curve analysis of pre incision amplitude change was greater than incision, heparin, and pre-clamp. A decrease greater than 50% of amplitude was predictive of perioperative stroke and major strokes alone from all baselines. Discussion: It should be considered that the purpose of an alarm is to present a warning in which an intervention is still possible to prevent the occurrence of a perioperative stroke. It should be recommended that a pre-incision baseline is used during CEA. The alarm criteria should be moved to provide an appropriate cushion to allow intervention. Latency changes were very specific but have limited sensitivity, and do not appear to be very useful, especially at the current alarm criteria of a 10% increase.