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BACKGROUND Stereotactic radiosurgery (SRS) is increasingly considered for selected olfactory groove meningiomas (OGMs). OBJECTIVE To investigate the safety and efficacy of SRS for OGMs. METHODS From 20 institutions participating in the International Radiosurgery Research Foundation, we pooled patients who underwent SRS for histologically confirmed or radiologically suspected WHO grade I OGMs and were followed for 6 mo or more after the SRS. RESULTS In total, 278 (median age 57 yr) patients underwent SRS for histologically confirmed (29%) or radiologically suspected (71%) WHO grade I OGMs Median treatment volume was 4.60 cm3 (range: 0.12-27.3 cm3), median prescription dose was 12 Gy, and median dose to the olfactory nerve was 11.20 Gy. During median post-SRS imaging follow-up of 39 mo (range: 6-240 mo), 43% of patients had partial or marginal response, 54% of patients had stable disease, and 3% of patients experienced progression. During median post-SRS clinical follow-up of 51 mo (range: 6-240 mo), 36 (13%) patients experienced clinical and/or radiological adverse radiation events (AREs). Elevated risk of AREs was associated with larger OGM volume (P = .009) and pre-SRS peritumoral T2/fluid-attenuated inversion-recovery signal abnormalities (P

BACKGROUND: Stereotactic radiosurgery (SRS) is increasingly used for management of perioptic meningiomas. OBJECTIVE: To study the safety and effectiveness of SRS for perioptic meningiomas. METHODS: From 12 institutions participating in the International Radiosurgery Research Foundation (IRRF), we retrospectively assessed treatment parameters and outcomes following SRS for meningiomas located within 3 mm of the optic apparatus. RESULTS: A total of 438 patients (median age 51 yr) underwent SRS for histologically confirmed (29%) or radiologically suspected (71%) perioptic meningiomas. Median treatment volume was 8.01 cm(3). Median prescription dose was 12 Gy, and median dose to the optic apparatus was 8.50 Gy. A total of 405 patients (93%) underwent single-fraction SRS and 33 patients (7%) underwent hypofractionated SRS. During median imaging follow-up of 55.6 mo (range: 3.15-239 mo), 33 (8%) patients experienced tumor progression. Actuarial 5-yr and 10-yr progression-free survival was 96% and 89%, respectively. Prescription dose of ≥12 Gy (HR: 0.310; 95% CI [0.141-0.679], P = .003) and single-fraction SRS (HR: 0.078; 95% CI [0.016-0.395], P = .002) were associated with improved tumor control. A total of 31 (10%) patients experienced visual decline, with actuarial 5-yr and 10-yr post-SRS visual decline rates of 9% and 21%, respectively. Maximum dose to the optic apparatus ≥10 Gy (HR = 2.370; 95% CI [1.086-5.172], P = .03) and tumor progression (HR = 4.340; 95% CI [2.070-9.097], P

BACKGROUND Atypical and anaplastic meningiomas have reduced progression-free/overall survival (PFS/OS) compared to benign meningiomas. Stereotactic radiosurgery (SRS) for atypical meningiomas (AMs) and anaplastic meningiomas (malignant meningiomas, MMs) has not been adequately described. OBJECTIVE To define clinical/radiographic outcomes for patients undergoing SRS for AM/MMs. METHODS An international, multicenter, retrospective cohort study was performed to define clinical/imaging outcomes for patients receiving SRS for AM/MMs. Tumor progression was assessed with response assessment in neuro-oncology (RANO) criteria. Factors associated with PFS/OS were assessed using Kaplan-Meier analysis and a Cox proportional hazards model. RESULTS A total of 271 patients received SRS for AMs (n = 233, 85.9%) or MMs (n = 38, 14.0%). Single-fraction SRS was most commonly employed (n = 264, 97.4%) with a mean target dose of 14.8 Gy. SRS was used as adjuvant treatment (n = 85, 31.4%), salvage therapy (n = 182, 67.2%), or primary therapy (1.5%). The 5-yr PFS/OS rate was 33.6% and 77.0%, respectively. Increasing age (hazard ratio (HR) = 1.01, P 15% (HR = 1.66, P

Improvements in systemic therapy are translating into more patients living longer with metastatic disease. Bone is the most common site of metastasis, where spinal lesions can result in significant pain impacting quality of life and possible neurological dysfunction resulting in a decline in performance status. Stereotactic body radiation therapy (SBRT) of the spine has emerged as a promising technique to provide durable local control, palliation of symptoms, control of oligoprogressive sites of disease, and possibly augment the immune response. SBRT achieves this by delivering highly conformal radiation therapy to allow for dose escalation due to a steep dose gradient from the planning target volume to nearby critical organs at risk. In our review, we provide an in-depth review and expert commentary regarding seminal literature that defined clinically meaningful toxicity endpoints with actionable dosimetric limits and/or clinical management strategies to mitigate toxicity potentially attributable to SBRT of the spine. We placed a spotlight on radiation myelopathy (de novo, reirradiation after conventional external beam radiation therapy or salvage after an initial course of spinal SBRT), plexopathy, vertebral compression fracture, pain flare, esophageal toxicity, myositis, and safety regarding combination with concurrent targeted or immune therapies.

BACKGROUND AND IMPORTANCE: Apraxia of speech is a disorder of articulatory coordination and planning in speech sound production. Its diagnosis is based on deficits in articulation, prosody, and fluency. It is often described concurrent with aphasia or dysarthria, while pure apraxia of speech is a rare entity. CLINICAL PRESENTATION: A right-handed man underwent focal surgical resection of a recurrent grade III astrocytoma in the left hemisphere dorsal premotor cortex located in the posterior middle frontal gyrus. After the procedure, he experienced significant long-term speech production difficulties. A battery of standard and custom language and articulatory assessments were administered, revealing intact comprehension and naming abilities, and preserved strength in orofacial articulators, but considerable deficits in articulatory coordination, fluency, and prosody—consistent with diagnosis of pure apraxia of speech. Tractography and resection volumes compared with publicly available imaging data from the Human Connectome Project suggest possible overlap with area 55b, an under-recognized language area in the dorsal premotor cortex and has white matter connectivity with the superior longitudinal fasciculus. CONCLUSION: The case reported here details a rare clinical entity, pure apraxia of speech resulting from resection of posterior middle frontal gyrus. While not a classical language area, emerging literature supports the role of this area in the production of fluent speech, and has implications for surgical planning and the general neurobiology of language.

BACKGROUND In patients who have previously undergone maximum radiation for metastatic brain tumors, a progressive enhancing inflammatory reaction (PEIR) that represents either tumor recurrence or radiation necrosis, or a combination of both, can occur. Magnetic resonance-guided laser-induced thermal therapy (LITT) offers a minimally invasive treatment option for this problem. OBJECTIVE To report our single-center experience using LITT to treat PEIRs after radiosurgery for brain metastases. METHODS Patients with progressive, enhancing reactions at the site of prior radiosurgery for metastatic brain tumors and who had a Karnofsky performance status of ≥70 were eligible for LITT. The primary endpoint was local control. Secondary end points included dexamethasone use and procedure-related complications. RESULTS Between 2010 and 2017, 59 patients who underwent 74 LITT procedures for 74 PEIRs met inclusion criteria. The mean pre-LITT PEIR size measured 3.4 ± 0.4 cm3. At a median follow-up of 44.6 wk post-LITT, the local control rate was 83.1%. Most patients were weaned off steroids post-LITT. Patients experiencing a post-LITT complication were more likely to remain on steroids indefinitely. The rate of new permanent neurological deficit was 3.4%. CONCLUSION LITT is an effective treatment for local control of PEIRs after radiosurgery for metastatic brain disease. When possible, we recommend offering LITT once PEIRs are identified and prior to the initiation of high-dose steroids for symptom relief.

Background Magnetic resonance-guided laser-induced thermal therapy (MRgLITT) is a novel, minimally invasive method currently being used to treat a wide range of intracranial pathologies. No accepted guidelines exist on what the appropriate magnetic resonance imaging (MRI) sequences are for evaluating short-term postablation changes, especially when patients are not able to receive gadolinium. Objective To evaluate which MRI sequences provide the greatest inter-rater reliability and least amount of variability in assessment of ablation volume after MRgLITT for intracranial neoplasms. Methods Twenty patients who received MRgLITT were included. Three raters calculated volumetric measurements on postprocedural axial spoiled gradient recalled (SPGR), fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and gradient echo (GRE) sequences. Measured volumes were analyzed using intraclass correlation to determine which protocol had the most concordance among the 3 raters. Results Postcontrast SPGR sequences were most concordant in our study, with an intraclass correlation of 0.981. DWI was the next-most concordant imaging sequence with an intraclass correlation of 0.958. The least concordant were GRE (0.895) and FLAIR (0.866) images. SPGR was also the least variable and had the most consistent volume ratings compared to the other sequences. Conclusion This study is the first to evaluate the inter-rater reliability of different MRI sequence protocols in the context of post-MRgLITT volumetric evaluation. SPGR postcontrast images facilitate the greatest interobserver concordance when characterizing post-MRgLITT tumor appearance and volumetrics, with DWI ranked second. Based on our findings, SPGR sequences are likely to yield the highest degree of concordance in post-MRgLITT lesion evaluation. When gadolinium cannot be given, DWI should provide the next most reliable estimation.

Background Diffuse low-grade gliomas (DLGGs) represent several pathological entities that infiltrate and invade cortical and subcortical structures in the brain. Objective To describe methods for rapid prototyping of DLGGs and surgically relevant anatomy. Methods Using high-definition imaging data and rapid prototyping technologies, we were able to generate 3 patient DLGGs to scale and represent the associated white matter tracts in 3 dimensions using advanced diffusion tensor imaging techniques. Results This report represents a novel application of 3-dimensional (3-D) printing in neurosurgery and a means to model individualized tumors in 3-D space with respect to subcortical white matter tract anatomy. Faculty and resident evaluations of this technology were favorable at our institution. Conclusion Developing an understanding of the anatomic relationships existing within individuals is fundamental to successful neurosurgical therapy. Imaging-based rapid prototyping may improve on our ability to plan for and treat complex neuro-oncologic pathology.

OBJECTIVE Current management of severe brachial plexus injury has undergone recent modifications, and surgical options have expanded. METHODS The case of a man with a severe closed brachial plexus injury resulting from a motorcycle accident is presented. The patient is found to have upper root avulsions that deprive him of function in the proximal arm. RESULTS Pre-, intra-, and postoperative decision making is reviewed by an expert in peripheral nerve surgery. Attention is paid to both diagnosis and management. A brief review of the literature pertaining to these points follows. CONCLUSION The recent expansion of surgical options for the management of severe brachial plexus injury has introduced significant controversy into this field.

OBJECTIVE: To compare cost-effectiveness of different strategies for completion angiography after cerebral aneurysm clipping. METHODS: A literature search was used to determine the outcome probabilities and costs of various strategies. The pooled results were used in a Markov cost-effectiveness model to compare quality-adjusted life-years and costs of each strategy. Sensitivity (threshold) analyses and Monte Carlo simulation were used to test variation in the model. RESULTS: Routine (for all cases) intraoperative angiography proved to be slightly more cost-effective than selective (only for cases deemed "high risk") intraoperative angiography, being both less costly and more effective. Routine postoperative angiography was the least cost-effective. However, in centers whose rates of clip-induced arterial compromise are much lower than the averages reported in the literature, selective angiography might be warranted. CONCLUSION: Routine intraoperative angiography remains the most cost-effective form of completion angiography after aneurysm clipping, at least at our present state of technology.

Objective Intraoperative lumbar cerebrospinal fluid drainage is frequently performed in a variety of neurosurgical procedures. A retrospective review is presented of the complications of lumbar cerebrospinal fluid drainage. Methods The records from 75 consecutive operations requiring intraoperative lumbar cerebrospinal drainage during a 1-year period at the Hospital of the University of Pennsylvania were reviewed to assess the types of complications attributable to spinal drainage and their rates of occurrence. The operations were categorized into 46 aneurysm clippings, 21 craniotomies for tumors, and 8 other cranial base procedures. Results Two patients developed transient postoperative neurological complications as a result of intracranial hypotension that resolved after epidural blood patching, with a reexploration craniotomy to drain an epidural collection performed in one patient. A third patient in the study developed a persistent deficit when intracranial hypotension led to intraoperative transtentorial herniation, which resulted in an unusual constellation of multiple brainstem infarcts that caused cranial neuropathy. Conclusion Complications of intraoperative lumbar cerebrospinal fluid drainage resulting in transient (2 of 75 patients, 3%) or persistent (1 of 75 patients, 1%) neurological deficits caused by intracranial hypotension occur infrequently and may be related to preexisting conditions such as hydrocephalus.

Background The role of radiotherapy after surgery for myxopapillary ependymoma (MPE) is unclear. Objective To review long-term outcomes after surgery, with or without radiation, for spinal MPE. Methods Fifty-one patients with spinal MPE treated from 1968 to 2007 were included. Associations between clinical variables and overall survival (OS), progression-free survival (PFS), and local control (LC) were tested with Cox regression analysis. Results The median age at diagnosis was 35 years (range, 8-63 years). Twenty patients (39%) had surgery alone, 30 (59%) had surgery plus radiotherapy (RT), and 1 (2%) had RT only. At a median follow-up of 11 years (range, 0.2-37 years), 10-year OS, PFS, and LC for the entire group were 93%, 63%, and 67%, respectively. Nineteen patients (37%) had disease recurrence, and the recurrence was mostly local (79%). Twenty-eight of 50 patients who had surgery (56%) had gross total resection; 10-year LC was 56% after surgery vs 92% after surgery and RT (log-rank P = .14); the median time of LC was 10.5 years for patients receiving gross total resection plus RT, and 4.75 years for gross total resection only (P = .03). Among 16 patients with subtotal resection and follow-up data, 10-year LC was 0% after surgery vs 65% for surgery plus RT (log-rank P = .008). On multivariate analyses adjusting for resection type, age older that 35 years at diagnosis and receipt of adjuvant radiation were associated with improved PFS (hazard ratio [HR]: 0.14, P = .003 and HR: 0.45, P = .009) and LC (HR: 0.22, P = .02 and HR: 0.45, P = .009). Conclusion Postoperative radiotherapy after resection of MPE was associated with improved PFS and LC.

BACKGROUND Enhancing lesions that progress after stereotactic radiosurgery are often tumor recurrence or radiation necrosis. Magnetic resonance-guided laser-induced thermal therapy (LITT) is currently being explored for minimally invasive treatment of intracranial neoplasms. OBJECTIVE To report the largest series to date of local control with LITT for the treatment of recurrent enhancing lesions after stereotactic radiosurgery for brain metastases. METHODS Patients with recurrent metastatic intracranial tumors or radiation necrosis who had previously undergone radiosurgery and had a Karnofsky performance status of >70 were eligible for LITT. Sixteen patients underwent a total of 17 procedures. The primary end point was local control using magnetic resonance imaging scans at intervals of >4 weeks. Radiographic outcomes were followed up prospectively until death or local recurrence (defined as >25% increase in volume compared with the 24-hour postprocedural scan). RESULTS Fifteen patients (age, 46-82 years) were available for follow-up. Primary tumor histology was non-small-cell lung cancer (n = 12) and adenocarcinoma (n = 3). On average, the lesion size measured 3.66 cm (range, 0.46-25.45 cm); there were 3.3 ablations per treatment (range, 2-6), with 7.73-cm depth to target (range, 5.5-14.1 cm), ablation dose of 9.85 W (range, 8.2-12.0 W), and total ablation time of 7.43 minutes (range, 2-15 minutes). At a median follow-up of 24 weeks (range, 4-84 weeks), local control was 75.8% (13 of 15 lesions), median progression-free survival was 37 weeks, and overall survival was 57% (8 of 14 patients). Two patients experience recurrence at 6 and 18 weeks after the procedure. Five patients died of extracranial disease progression; 1 patient died of neurological progression elsewhere in the brain. CONCLUSION Magnetic resonance imaging-guided LITT is a well-tolerated procedure and may be effective in treating tumor recurrence/radiation necrosis.

OBJECTIVE AND IMPORTANCE: We report four cases of anomalous anterior choroidal artery supply to the temporal, parietal, and occipital cortical regions normally supplied by branches of the posterior cerebral artery. Three of these cases were associated with significant intracranial vascular pathology. We examine the embryological basis for the anomalous vascular anatomy to emphasize the potential variability of the anterior choroidal artery distribution and illustrate the spectrum of this variability angiographically. These variants may also have significant implications for surgical and endovascular treatment. CLINICAL PRESENTATION: One patient was diagnosed with an arteriovenous malformation, and two patients were diagnosed with aneurysms, one of which presented with a subarachnoid hemorrhage. INTERVENTION: The patient with the arteriovenous malformation underwent preoperative embolization and surgical resection, one patient with an aneurysm was treated via surgical clipping, and the other aneurysm underwent endovascular coiling. CONCLUSION: This group of patients illustrates an underemphasized but potentially important vascular anomaly. Phylogeny and embryology of the intracerebral vessels suggest a mechanism related to transposed distributions. Careful attention must be directed to the microvascular anatomy of the intracerebral circulation so that these anomalies are recognized and, if necessary, factored into surgical and interventional planning.

BACKGROUND Meningeal hemangiopericytoma (M-HPC) is a rare entity. OBJECTIVE To characterize our institutional experience in treating M-HPC. METHODS We reviewed the medical records of patients with M-HPC evaluated at The University of Texas M.D. Anderson Cancer Center between 1979 and 2009. RESULTS We identified 63 patients diagnosed between 1979 and 2009 with M-HPC treated with surgery alone or with postoperative radiotherapy (PORT). The majority were male (59%) and with a median age of 40.9 years (range, 0-71). Gross total resection (GTR) predominated (n = 31, 49%) followed by subtotal resection (n = 23, 37%) and unknown status (n = 9, 14.3%). PORT was delivered to 39 of the 63 patients (62%). The 5-, 10-, and 15-year overall survival were 90%, 68%, and 28%, respectively. The 5-, 10-, and 15-year local control (LC) were 70%, 37%, and 20%, respectively. The 5-, 10-, and 15-year metastasis-free survival were 85%, 39%, and 7%. PORT resulted in improved LC (hazard ratio [HR] 0.38, P = .008). Radiotherapy (RT) dose ≥60 Gy correlated with improved LC relative to

BACKGROUND: Injuries to the upper trunk of the brachial plexus are debilitating, affecting primarily shoulder abduction and elbow flexion. Treatment is aimed at restoring shoulder stabilization, shoulder abduction, and elbow flexion and may be accomplished by nerve grafting, nerve transfer, or functional muscular transfer. OBJECTIVE: To describe the double fascicular nerve transfer with the goal of restoring elbow flexion. METHODS: The double fascicular nerve transfer involves transferring an ulnar nerve fascicle to the musculocutaneous nerve innervating the biceps muscle and a median nerve fascicle transfer to a branch of musculocutaneous nerve supplying the brachialis muscle. RESULTS: The double fascicular nerve transfer is effective in restoring elbow flexion after severe upper-trunk brachial plexus injuries. CONCLUSION: Advantages of this procedure are that the nerve repair is done very close to the target muscle for reinnervation, so time to reinnervation is minimized, and the surgery takes place distal to the site of injury in nontraumatized tissue.