Edward A Monaco

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

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Publications (43)116.88 Total impact

  • 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.
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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; · 3.12 Impact Factor
  • Neurosurgery 12/2014; 75(6):N17-8. · 3.03 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 cm(3) (range 0.4-22 cm(3)), 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 cm(3) 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; · 3.23 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; · 3.23 Impact Factor
  • Neurosurgery 10/2014; 75(4):N23-N24. · 3.03 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; · 3.12 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; · 2.42 Impact Factor
  • Neurosurgery 08/2014; 75(2):N23-N25. · 3.03 Impact Factor
  • Neurosurgery 06/2014; 74(6):N8-9. · 3.03 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; · 3.12 Impact Factor
  • Neurosurgery 04/2014; 74(4):N9-N11. · 3.03 Impact Factor
  • Neurosurgery 02/2014; 74(2):N15-6. · 3.03 Impact Factor
  • Philip Lee, Edward A Monaco, Robert M Friedlander
    Neurosurgery 12/2013; 73(6):N13-N14. · 3.03 Impact Factor
  • Neurosurgery 10/2013; 73(4):N16-7. · 3.03 Impact Factor
  • Neurosurgery 08/2013; 73(2):N18-20. · 3.03 Impact Factor
  • Neurosurgery 06/2013; 72(6):N19-N20. · 3.03 Impact Factor
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    ABSTRACT: BACKGROUND: Infectious intracranial aneurysms (IIAs) are rare and potentially devastating. First-line management involves intravenous antibiotics, with surgical or endovascular management reserved for cases of failed medical treatment or aneurysmal rupture. Endovascular therapy has become the primary approach for treating these small, distally located aneurysms. Liquid embolic agents are well suited for use because of their ability to fill the aneurysm and parent vessel. We present our experience in treating these aneurysms via Onyx embolization and review the literature. METHODS: We retrospectively reviewed the endovascular treatment of IIAs at our institution from 2010 to 2012. Eight patients with 16 IIAs ranging in size from 1 to 16 mm underwent treatment. Seven of the patients initially presented after aneurysmal rupture. Onyx was pushed until the aneurysm and parent artery were filled. Confirmation of aneurysmal occlusion was made by repeat cerebral angiography. RESULTS: One symptomatic stroke occurred after embolization. Fourteen of the 16 aneurysms have been evaluated with follow-up angiography and remain occluded. CONCLUSIONS: Treatment of IIAs using an endovascular approach with Onyx is safe and effective.
    Journal of Neurointerventional Surgery 05/2013; · 2.50 Impact Factor
  • Edward A Monaco, Robert M Friedlander
    Neurosurgery 04/2013; 72(4):N18-9. · 3.03 Impact Factor
  • Neurosurgery 02/2013; 72(2):N17-N19. · 3.03 Impact Factor