Edward A Monaco

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

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Publications (52)158.68 Total impact

  • Edward A. Monaco · Zachary Tempel · Ajay Niranjan · L. Dade Lunsford ·
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    ABSTRACT: Optimal management of craniopharyngiomas continues to be controversial. Traditionally, radical tumor resection was sought, often at a high cost to patients. A more modern view of craniopharyngioma treatment balances the risks of tumor control with visual, endocrinological, neurological, and quality-of-life components. Patients typically require multimodal therapy to achieve these goals. Intracavitary radiation therapy for brain tumors with β-emitting radioisotopes was first described in the 1950s. Stereotactic instillation of phosphorus-32, yttrium-90, and rhenium-186 into predominantly cystic craniopharyngiomas is a minimally invasive technique that has proven safe and effective. Tumor control and complication rates compare favorably with those for surgery and other forms of radiation therapy. There are limited data on quality of life using validated measures in this patient cohort. Despite this, craniopharyngioma treatment must be tailored to the individual and intracavitary radiation should be seriously considered in patients with predominantly cystic tumors.
    Craniopharyngiomas, 12/2015: pages 391-403; , ISBN: 9780124167063

  • International journal of radiation oncology, biology, physics 11/2015; 93(3):E347-E348. DOI:10.1016/j.ijrobp.2015.07.1433 · 4.26 Impact Factor

  • International journal of radiation oncology, biology, physics 11/2015; 93(3):E499. DOI:10.1016/j.ijrobp.2015.07.1821 · 4.26 Impact Factor
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    ABSTRACT: Introduction Traumatic bilateral locked facet joints occur with extreme rarity in the lumbar spine. A careful review of the literature revealed only three case reports. Clinical Presentation We present the case of a 36 year-old male who suffered bilateral L4–5 facet fracture dislocations following a motor vehicle collision. The dislocation was associated with disruption of the posterior elements and a Grade II anterolisthesis of L4 on L5 as well as an epidural hematoma resulting in severe canal narrowing, with the patient remaining neurologically intact on presentation. The patient underwent open reduction with L3 to S1 pedicle screw fixation and arthrodesis to treat this highly unstable injury. Conclusion The existing literature and a biomechanics review of the lumbar spine are described in the context of the presented case in addition to a proposed mechanism for such dislocations.
    European Spine Journal 09/2015; DOI:10.1007/s00586-015-4245-y · 2.07 Impact Factor
  • Raghav Gupta · Christopher Kim · Nitin Agarwal · Bryan Lieber · Edward A Monaco ·
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    ABSTRACT: Parkinson's disease (PD) is a common neurodegenerative disorder characterized by the presence of Lewy Bodies and a reduction in the number of dopaminergic neurons in the substantia nigra of the basal ganglia. Common symptoms of Parkinson's disease include: a reduction in control of voluntary movements, rigidity, and tremors in. Such symptoms are marked by a severe deterioration in motor function. The causes of Parkinson's disease in many cases are unknown. PD has been found to be prominent in several notable people, including Adolf Hitler, the Chancellor of Germany and Führer of Nazi Germany during World War II. It is believed that Adolf Hitler suffered from idiopathic Parkinson's disease throughout his life. However, the effect of Parkinson's disease on Adolf Hitler's decision making during World War II is largely unknown. Here we examine the potential role of Parkinson's disease in shaping Hitler's personality and influencing his decision-making. We purport that Germany's defeat in World War II was influenced by Hitler's questionable and risky decision-making and his inhumane and callous personality, both of which were likely affected by his Parkinson's condition. Likewise his paranoid disorder marked by intense anti-Semitic beliefs influenced his treatment of Jews and other non-Germanic peoples. We also suggest that the condition played an important role in his eventual political decline. Copyright © 2015 Elsevier Inc. All rights reserved.
    World Neurosurgery 06/2015; 84(5). DOI:10.1016/j.wneu.2015.06.014 · 2.88 Impact Factor
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    ABSTRACT: To perform a failure modes and effects analysis (FMEA) study for Gamma Knife (GK) radiosurgery processes at our institution based on our experience with the treatment of more than 13,000 patients. A team consisting of medical physicists, nurses, radiation oncologists, neurosurgeons at the University of Pittsburgh Medical Center and an external physicist expert was formed for the FMEA study. A process tree and a failure mode table were created for the GK procedures using the Leksell GK Perfexion and 4C units. Three scores for the probability of occurrence (O), the severity (S), and the probability of no detection (D) for failure modes were assigned to each failure mode by each professional on a scale from 1 to 10. The risk priority number (RPN) for each failure mode was then calculated (RPN = OxSxD) as the average scores from all data sets collected. The established process tree for GK radiosurgery consists of 10 sub-processes and 53 steps, including a sub-process for frame placement and 11 steps that are directly related to the frame-based nature of the GK radiosurgery. Out of the 86 failure modes identified, 40 failure modes are GK specific, caused by the potential for inappropriate use of the radiosurgery head frame, the imaging fiducial boxes, the GK helmets and plugs, and the GammaPlan treatment planning system. The other 46 failure modes are associated with the registration, imaging, image transfer, contouring processes that are common for all radiation therapy techniques. The failure modes with the highest hazard scores are related to imperfect frame adaptor attachment, bad fiducial box assembly, overlooked target areas, inaccurate previous treatment information and excessive patient movement during MRI scan. The implementation of the FMEA approach for Gamma Knife radiosurgery enabled deeper understanding of the overall process among all professionals involved in the care of the patient and helped identify potential weaknesses in the overall process.
    Medical Physics 06/2015; 42(6):3692. DOI:10.1118/1.4926078 · 2.64 Impact Factor
  • Edward A Monaco · Zachary Tempel ·

    Neurosurgery 04/2015; 76(4):N10-1. DOI:10.1227/NEU.0000000000000700 · 3.62 Impact Factor
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    ABSTRACT: Vestibular schwannoma patients with Gardner-Robertson (GR) class I hearing seek to maintain high-level hearing whenever possible. To evaluate hearing outcomes at 2 to 3 years in GR class I patients who underwent Gamma Knife radiosurgery (GKRS). Sixty-eight patients with GR class I hearing were identified between 2006 and 2009. Twenty-five patients had no subjective hearing loss (group A) and 43 patients reported subjective hearing loss (group B) before GKRS. The median tumor volume (1 cm) and tumor margin dose (12.5 Gy) were the same in both groups. Serviceable hearing retention rates (GR grade I or II) were 100% for group A compared with 81% at 1 year, 60% at 2 years, and 57% at 3 years after GKRS for group B patients. Group A patients had significantly higher rates of hearing preservation in either GR class I (P < .001) or GR class II (P < .001). Patients with a pure tone average (PTA) <15 dB before GKRS had significantly higher rates of preservation of GR class I or II hearing. At 2 to 3 years after GKRS, patients without subjective hearing loss or a PTA <15 dB had higher rates of grade I or II hearing preservation. Modification of the GR hearing classification into 2 groups of grade I hearing (group A, those with no subjective hearing loss and a PTA <15 dB; and group B, those with subjective hearing loss and a PTA >15 dB) may be useful to help predict hearing preservation rates at 2 to 3 years after GKRS. CI, confidence intervalGKRS, Gamma Knife radiosurgeryGR, Gardner-RobertsonHR, hazard ratioPTA, pure tone averageSDS, speech discrimination score.
    Neurosurgery 02/2015; 76(5). DOI:10.1227/NEU.0000000000000674 · 3.62 Impact Factor
  • Zachary J Tempel · Robert M Friedlander · Edward A Monaco ·

    Neurosurgery 02/2015; 76(2):N11-N13. DOI:10.1227/01.neu.0000460591.70933.9b · 3.62 Impact Factor
  • Edward A Monaco · Ajay Niranjan · L Dade Lunsford ·
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    ABSTRACT: Stereotactic radiosurgery (SRS) has evolved into a mainstay in the primary and adjuvant management of most intracranial tumors. Central neurocytomas are rare, usually benign, intraventricular tumors that can be challenging to completely resect and often recur. Adjuvant therapy has been suggested for residual or recurrent tumors, especially in the setting of atypical neurocytomas. The limited data available suggest that SRS is a highly effective treatment approach for primary and adjuvant therapy, with tumor control rates of 80% to 90%. Due to its highly conformal and selective nature, SRS avoids the inconvenience and delayed toxicity of conventional radiation therapy. Copyright © 2015 Elsevier Inc. All rights reserved.
    Neurosurgery Clinics of North America 01/2015; 26(1):37-44. DOI:10.1016/j.nec.2014.09.008 · 1.44 Impact Factor
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    ABSTRACT: Delayed toxicity after whole brain radiation therapy (WBRT) is of increasing concern in patients who survive more than one year with brain metastases from breast cancer. Radiation-related white matter toxicity is detected by magnetic resonance imaging (MRI) and has been correlated with neurocognitive dysfunction. This study assessed the risk of developing white matter changes (WMC) in breast cancer patients who underwent either WBRT plus stereotactic radiosurgery (SRS) or SRS alone. We retrospectively compared 35 patients with breast cancer brain metastases who received WBRT and SRS to 30 patients who only received SRS. All patients had evaluable imaging at a median of one year after their initial management. The development of white matter T2 prolongation as detected by T2 or FLAIR imaging was graded: grade 1 = little or no white matter T2 hyperintensity; grade 2 = limited periventricular hyperintensity; and grade 3 = diffuse white matter hyperintensity. After WBRT plus SRS, patients demonstrated a significantly higher incidence of WMC (p < 0.0001). After one year, 71.5 % of patients whose treatment included WBRT demonstrated WMC (42.9 % grade 2; 28.6 % grade 3). Only one patient receiving only SRS developed WMC. In long-term survivors of breast cancer, the risk of WMC was significantly reduced when SRS alone was used for management. Further prospective studies are necessary to determine how these findings correlate with neurocognitive toxicity. WBRT usage as initial management of limited brain disease should be replaced by SRS alone to reduce the risk of delayed white matter toxicity.
    Journal of Neuro-Oncology 12/2014; 121(3). DOI:10.1007/s11060-014-1670-4 · 3.07 Impact Factor
  • Nathan T Zwagerman · Robert M Friedlander · Edward A Monaco ·

    Neurosurgery 12/2014; 75(6):N17-8. DOI:10.1227/01.neu.0000457197.94533.68 · 3.62 Impact Factor
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    ABSTRACT: Object: A visual field deficit resulting from the management of an arteriovenous malformation (AVM) significantly impacts a patient's quality of life. The present study was designed to investigate the clinical and radiological outcomes of stereotactic radiosurgery (SRS) performed for AVMs involving the postgeniculate visual pathway. Methods: In this retrospective single-institution analysis, the authors reviewed their experience with Gamma Knife surgery for postgeniculate visual pathway AVMs performed during the period between 1987 and 2009. Results: During the study interval, 171 patients underwent SRS for AVMs in this region. Forty-one patients (24%) had a visual deficit prior to SRS. The median target volume was 6.0 cm3 (range 0.4-22 cm3), and 19 Gy (range 14-25 Gy) was the median margin dose. Obliteration of the AVM was confirmed in 80 patients after a single SRS procedure at a median follow-up of 74 months (range 5-297 months). The actuarial rate of total obliteration was 67% at 4 years. Arteriovenous malformations with a volume<5 cm3 had obliteration rates of 60% at 3 years and 79% at 4 years. The delivered margin dose proved significant given that 82% of patients receiving ≥22 Gy had complete obliteration. The AVM was completely obliterated in an additional 18 patients after they underwent repeat SRS. At a median of 25 months (range 11-107 months) after SRS, 9 patients developed new or worsened visual field deficits. One patient developed a complete homonymous hemianopia, and 8 patients developed quadrantanopias. The actuarial risk of sustaining a new visual deficit was 3% at 3 years, 5% at 5 years, and 8% at 10 years. Fifteen patients had hemorrhage during the latency period, resulting in death in 9 of the patients. The annual hemorrhage rate during the latency interval was 2%, and no hemorrhages occurred after confirmed obliteration. Conclusions: Despite an overall treatment mortality of 5%, related to latency interval hemorrhage, SRS was associated with only a 5.6% risk of new visual deficit and a final obliteration rate close to 80% in patients with AVMs of the postgeniculate visual pathway.
    Journal of Neurosurgery 11/2014; 122(2):1-8. DOI:10.3171/2014.10.JNS1453 · 3.74 Impact Factor
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    ABSTRACT: Object: Gamma Knife radiosurgery (GKRS) is the least invasive treatment option for medically refractory, intractable trigeminal neuralgia (TN) and is especially valuable for treating elderly, infirm patients or those on anticoagulation therapy. The authors reviewed pain outcomes and complications in TN patients who required 3 radiosurgical procedures for recurrent or persistent pain. Methods: A retrospective review of all patients who underwent 3 GKRS procedures for TN at 4 participating centers of the North American Gamma Knife Consortium from 1995 to 2012 was performed. The Barrow Neurological Institute (BNI) pain score was used to evaluate pain outcomes. Results: Seventeen patients were identified; 7 were male and 10 were female. The mean age at the time of last GKRS was 79.6 years (range 51.2-95.6 years). The TN was Type I in 16 patients and Type II in 1 patient. No patient suffered from multiple sclerosis. Eight patients (47.1%) reported initial complete pain relief (BNI Score I) following their third GKRS and 8 others (47.1%) experienced at least partial relief (BNI Scores II-IIIb). The average time to initial response was 2.9 months following the third GKRS. Although 3 patients (17.6%) developed new facial sensory dysfunction following primary GKRS and 2 patients (11.8%) experienced new or worsening sensory disturbance following the second GKRS, no patient sustained additional sensory disturbances after the third procedure. At a mean follow-up of 22.9 months following the third GKRS, 6 patients (35.3%) reported continued Score I complete pain relief, while 7 others (41.2%) reported pain improvement (BNI Scores II-IIIb). Four patients (23.5%) suffered recurrent TN following the third procedure at a mean interval of 19.1 months. Conclusions: A third GKRS resulted in pain reduction with a low risk of additional complications in most patients with medically refractory and recurrent, intractable TN. In patients unsuitable for other microsurgical or percutaneous strategies, especially those receiving long-term oral anticoagulation or antiplatelet agents, GKRS repeated for a third time was a satisfactory, low risk option.
    Journal of Neurosurgery 10/2014; 122(1):1-11. DOI:10.3171/2014.9.JNS132779 · 3.74 Impact Factor
  • Stephen Johnson · Robert M Friedlander · Edward A Monaco ·

    Neurosurgery 10/2014; 75(4):N23-N24. DOI:10.1227/01.neu.0000454764.67990.cb · 3.62 Impact Factor
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    ABSTRACT: In order to evaluate long term clinical and imaging outcomes, the authors retrospectively reviewed our 22-year experience using stereotactic radiosurgery (SRS) for tentorial meningiomas. Thirty-nine patients with tentorial meningiomas underwent SRS using various Gamma Knife technologies between 1988 and 2010. The most common presenting symptoms were headache, dizziness or disequilibrium, and ataxia. The median tumor volume was 4.6 cm(3) (range 0.5-36.6 cm(3)) and the median radiation dose to the tumor margin was 14 Gy (range 8.9-18 Gy). The median follow-up period was 41 months (range 6-183 months). At the last imaging follow-up, tumor volumes decreased in 22 patients (57 %), remained stable in 13 patients (33 %), and increased in 4 patients (10 %). The progression-free survival after SRS was 97 % at 1 year, and 92 % at 5 years. At the last clinical follow-up, 35 patients (90 %) showed no change in symptoms, 1 patient (2 %) showed improvement of their neurologic symptom, and 3 patients (8 %) demonstrated worsening symptoms. The rate of symptom worsening after SRS was 5 % at 1 year, and 10 % at 5 years. Asymptomatic peritumoral edema after SRS occurred in 2 patients (5 %). Symptomatic adverse radiation effect developed in 2 patients (5 %). SRS for tentorial meningiomas provided long-term effective tumor control and a low risk of radiation related complications.
    Journal of Neuro-Oncology 09/2014; 121(1). DOI:10.1007/s11060-014-1605-0 · 3.07 Impact Factor
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    ABSTRACT: Objective Stereotactic radiosurgery (SRS) has evolved to become an established, well-studied treatment modality for intracranial pathologies traditionally treated with more invasive neurosurgical management. As the field expands, among neurosurgeons and across multiple disciplines, resident training will become increasingly crucial. Methods In this review we reflect on 25 years of SRS at the University of Pittsburgh Medical Center (UPMC) and the development of formal training in this area at our institution. We describe the formal resident rotation, fellowship opportunities, and training courses for multidisciplinary physician teams and allied health professionals. Results The number of SRS cases performed annually has significantly increased in recent years, and indeed surpassed caseloads for certain more traditional surgeries. Residents report high rates of expectation for including SRS in future practice, yet participate in only a small fraction of annual cases. The formal PGY-3 rotation established at UPMC provides a way to expose and educate residents in this growing subspecialty within the confines of duty hour regulations. In combination with extended clinical elective opportunities and post-residency fellowships, this rotation prepares residents at our institution for the use of SRS in future clinical practice. Conclusion SRS is a rapidly expanding field that requires a unique skill set and current neurosurgical resident training often does not fully prepare trainees for its use in clinical practice. Focused resident training is necessary to ensure trainees are proficient in this specialty and well equipped to become leaders in the field.
    World Neurosurgery 09/2014; 82(3-4). DOI:10.1016/j.wneu.2014.05.016 · 2.88 Impact Factor
  • Edward A Monaco · Zachary J Tempel · Robert M Friedlander ·

    Neurosurgery 08/2014; 75(2):N23-N25. DOI:10.1227/01.neu.0000452321.37602.77 · 3.62 Impact Factor
  • David M Panczykowski · Edward A Monaco · Robert M Friedlander ·

    Neurosurgery 06/2014; 74(6):N8-9. DOI:10.1227/NEU.0000000000000365 · 3.62 Impact Factor
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    ABSTRACT: Esophageal carcinoma rarely results in intracranial metastases but when it does, the patient prognosis is grim. Because of its rarity outcomes after stereotactic radiosurgery (SRS) are not known. We sought to evaluate the outcomes of SRS in the management of esophageal cancer that has spread to the brain. This single institution retrospective analysis reviewed our experience with esophageal metastasis from 1987 to 2013. Thirty patients (36 SRS procedures) with a median age of 59 (37-86 years) underwent Gamma knife(®) SRS. The esophageal origin was adenocarcinoma in 26 patients (87 %), squamous cell carcinoma in 3 patients (10 %), and mixed neuroendocrine carcinoma in 1 patient (3 %). Fifteen patients were treated for a single metastasis and 15 patients were treated for multiple metastases for a total of 87 tumors. The median tumor volume was 5.7 cm(3) (0.5-44 cm(3)) with a median marginal dose of 17 Gy (12-20 Gy). The median survival time from the diagnosis of brain metastasis was 8 months and the median survival from SRS was 4.2 months. This corresponded to a 6-month survival of 45 % and a 12-month survival of 19 % after SRS. A higher KPS at the time of procedure was associated with an increase in survival (p = 0.023). The local tumor control rate in this group was 92 %. Four patients had repeat SRS for new metastatic deposits. One patient developed a new neurological deficit after SRS. SRS proved an effective means of providing local control for esophageal metastases to the brain. Concomitant systemic disease progression at the time of brain metastasis resulted in poor long-term survival.
    Journal of Neuro-Oncology 04/2014; 118(1). DOI:10.1007/s11060-014-1408-3 · 3.07 Impact Factor