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Background Colloid cysts (CC) have been associated with neurocognitive function (NCF) decline, both preoperatively and after resection. Factors such as local pressure on the fornix and hydrocephalus are thought to contribute to preoperative NCF decline. The potential cause of postoperative decline is thought to be forniceal injury during surgery. In the current series, we describe NCF outcomes amongst patients with CC, both nonoperated and operated. Methods A total of 36 patients (23 operated, 13 nonoperated) were included in this retrospective study. All patients underwent at least 1 NCF evaluation battery. Of the 13 nonoperated cases, 5 had follow-up tests too. Of the 23 operated, 14 had both pre- and postoperative tests, and 8 had early and late postoperative tests. Results There was no significant difference in baseline NCF between nonoperated and operated cases (as evaluated preoperatively). Nonoperated patients had a stable NCF test over time. Patients who were operated showed a significant improvement after surgery in several NCF variables. There was no significant change in NCF between early and late postoperative evaluation. None of the operated patients had a postoperative NCF decline. Conclusions Patients with CC should undergo routine NCF testing with a standardized protocol, whether they are operated or followed. Surgery has a positive impact on NCF; however, it remains to be determined if the improvement is solely secondary to treatment of hydrocephalus, or to a reduction of local pressure on the fornices. It remains to be determined whether the surgical technique, that is, endoscopic, interhemispheric, or transcortical, has an impact on NCF outcome.

Background Gliomatosis cerebri is a rare diffusely infiltrating malignant glial neoplasm. Presenting symptoms include seizures, neurologic deficits, and frequently symptoms related to increased intracranial pressure (ICP). Surgical intervention, including brain biopsy, may induce worsening of these neurologic symptoms. We reviewed our database to identify prognostic and risk factors for perioperative deterioration specifically associated with elevated ICP. Methods Between 2006 and 2014, 78 patients were treated for gliomatosis cerebri. Ten patients required perioperative emergent treatment for elevated ICP. The clinical course and outcome of these 10 patients (study group) were characterized and compared with the remaining 68 patients. Results The study group patients developed life-threatening symptoms of increased ICP and required urgent decompressive craniectomy ( n = 5 urgent decompressive craniectomy after biopsy, n = 2 urgent decompressive craniectomy on admission) or aggressive medical therapy ( n = 3). Demographic and clinical variables were similar in both groups. In patients with severe symptoms of increased ICP, enhancing tumor volume was significantly greater than in asymptomatic patients. Radiologic evidence of obliteration of the basal cisterns and herniation was more common in symptomatic patients. The proliferation index in the biopsy specimens of tumors was also significantly higher in patients with symptomatic ICP elevation. Conclusions Clinical symptoms and radiologic appearance suggestive of elevated ICP at presentation, volume of contrast enhancement, and high Ki-67 proliferation index may predict the need for aggressive rapid treatment to control ICP in a small but significant subset of patients with GC. Further studies are needed to clarify the biologic basis for the unusual clinical course in these tumors.

Introduction Radiation necrosis (RN) and pseudoprogression are known as postradiation treatment effects and may simulate tumor progression. The disease course of glioblastoma patients who had developed RN and the impact of resecting RN on survival have not been evaluated. This study examines the clinical course of patients considered candidates for repeat surgery for a recurring brain mass proven to be RN and compared these with patients who had true tumor recurrence at surgery. Methods Of 159 patients with glioblastoma who were reoperated on because of a presumed recurrent tumor requiring repeat surgery, 18 had RN as the major component of the resected mass. The characteristics and outcome of these 18 patients were retrospectively analyzed and compared with patients in whom active and bulky tumor was found during surgery. Results Radiation necrosis occurred significantly earlier than true tumor recurrence. Patients with RN harbored larger lesions and were significantly more symptomatic before the second surgery. Most patients with RN who underwent GTR of the lesion in the second operation experienced faster resolution of the surrounding edema compared with patients who underwent STR or biopsy only. There was no significant difference in survival between the 2 groups. Conclusions These data provide an opportunity to examine the clinical course of a selected group of patients with histologically verified RN. Although RN is associated with more severe neurologic symptoms that improve after surgery, its occurrence or surgical removal carries no survival advantage compared with patients who undergo a repeat operation for true tumor recurrence.

Background Whole brain radiation treatment (WBRT) is considered standard treatment for BM. However, exposing large volumes of normal brain tissue to irradiation can cause neurotoxicity. This study describes our experience with 100 consecutive patients with brain metastases who were managed with surgical extirpation followed by stereotactic radiosurgery (SRS) to the resection cavity. Methods Patients with 1–3 brain metastases (BM), who underwent resection of 1–2 BM between June 2005 and December 2013, were treated with SRS directed to the tumor cavity and for any synchronous BM. Local and distant treatment failures were determined based on neuroimaging. Kaplan–Meier curves were generated for local and distant failure rates and overall survival. Results One hundred and two resection cavities were treated with SRS in 100 consecutive patients. Thirty-two additional synchronous metastases were treated in 27 patients during the same session. The median overall survival was 18.9 months. Local control rate at 1 year was 84%. Longer delays between surgery and SRS were associated with increased risk of local failure (hazard ratio, −1.46; P = 0.02). Distant progression occurred in 44% of the patients at a mean of 8.8 ± 6.6 months after SRS treatment. Ten cases of leptomeningeal spread occurred around the resection cavities (9.8%). Central nervous system failure was not significantly associated with survival. Multivariate Cox regression analysis showed that recursive partitioning analysis and active systemic disease were significantly associated with survival. Conclusion The strategy described provides acceptable local disease control when compared with WBRT following surgery. This approach can delay and even annul WBRT in the majority of selected BM patients, especially recursive partitioning analysis class I patients. SRS should be scheduled as soon as possible after surgery.

Objective Sarcoma rarely metastasizes to the brain, and there are no specific treatment guidelines for these tumors. The recursive partitioning analysis (RPA) classification is a well-established prognostic scale used in many malignancies. In this study we assessed the clinical characteristics of metastatic sarcoma to the brain and the validity of the RPA classification system in a subset of 21 patients who underwent surgical resection of metastatic sarcoma to the brain Methods We retrospectively analyzed the medical, radiological, surgical, pathological, and follow-up clinical records of 21 patients who were operated for metastatic sarcoma to the brain between 1996 and 2012. Gliosarcomas, sarcomas of the head and neck with local extension into the brain, and metastatic sarcomas to the spine were excluded from this reported series. Results The patients' mean age was 49.6 ± 14.2 years (range, 25–75 years) at the time of diagnosis. Sixteen patients had a known history of systemic sarcoma, mostly in the extremities, and had previously received systemic chemotherapy and radiation therapy for their primary tumor. The mean maximal tumor diameter in the brain was 4.9 ± 1.7 cm (range 1.7–7.2 cm). The group's median preoperative Karnofsky Performance Scale was 80, with 14 patients presenting with Karnofsky Performance Scale of 70 or greater. The median overall survival was 7 months (range 0.2–204 months). The median survival time stratified by the Radiation Therapy Oncology Group RPA classes were 31, 7, and 2 months for RPA class I, II, and III, respectively ( P = 0.0001). Conclusions This analysis is the first to support the prognostic utility of the Radiation Therapy Oncology Group RPA classification for sarcoma brain metastases and may be used as a treatment guideline tool in this rare disease.

Background Bevacizumab (BVZ) is an antiangiogenic agent approved by the Food and Drug Administration that is used for the treatment of recurrent glioblastoma. Complications related to impaired healing may adversely affect patients resected for recurrent high-grade glioma (HGG) after treatment with BVZ. Objective To examine the complication rate, outcome, and tumor vasculature in patients resected for recurrent HGG after treatment with BVZ. Methods Data were reviewed retrospectively from patients undergoing surgery for recurrent HGG after treatment with BVZ. Results were compared with a control group of recurrently operated BVZ-naive HGG. Tumor samples and magnetic resonance imaging scans were analyzed. Results Fifteen patients underwent HGG resection after progression after BVZ. Forty-four BVZ-naive patients who underwent surgeries for tumor recurrence were included as controls. Median time from BVZ treatment to surgery was 30 days (2–107). Median overall survival from time of tumor diagnosis was 21.0 months (12–83.0), and median survival from post-BVZ surgery was 5.0 months (2.0–19.0), compared with 8.1 months in BVZ-naive controls measured from time of their last reoperation. Five of the 15 patients survived 6 or more months after post-BVZ surgery. Nine patients developed postsurgical complications requiring intervention. Complication rates for surgery after BVZ treatment were 66.7% compared with 38.6% in the control group (P = 0.077). We did not see overt changes in histopathology or immunohistochemistry staining; however, tumor vasculature in tumors resected after treatment with BVZ showed a significant decrease in mean vessel density. Conclusions Surgery for recurrent HGG may be feasible in a select group of patients. Mean tumor vessel density may be decreased after treatment with BVZ.

he essence of immunotherapy for cancer is to stimulate the immune system against cancer cells while sparing T normal tissue. This approach shows potential promise against many cancer types, including invasive and uniformly fatal malignant gliomas. Malignant glioma is a highly infiltrative tumor with prominent tumor cells that spread far beyond themain tumor mass. This infiltrative nature of gliomas highlights the need for a unique treatment modality that may reach and destroy these infiltrating cells.

Despite selection process before awake-craniotomy, some patients experience an unexpected decline in language functions in the operating room (OR), compared with their baseline evaluation, which may impair their functional monitoring. To investigate this phenomenon we prospectively compared language function the day before surgery and on entrance to the OR.Data were collected prospectively from consecutive patients undergoing awake-craniotomy with intraoperative cortical mapping for resection of gliomas affecting language areas. Language functions of 79 patients were evaluated and compared 1-2 days before surgery and after entering the OR. Changes in functional linguistic performance were analyzed with respect to demographic, clinical, and pathologic characteristics.There was a significant decline in language function, beyond sedation effect, after entering the OR, (from median/interquartile range: 0.94/0.72-0.98 to median/interquartile range: 0.86/0.51-0.94; Z = -7.19, P0.001). Univariate analyses revealed that this decline was related to age, preoperative Karnofsky Performance Scale, tumor location, tumor pathology, and preexisting language deficits. Multivariate stepwise regression identified tumor pathology and the presence of preoperative language deficit as significant independent predictors for this functional decline.Patients undergoing awake-craniotomy may experience a substantial decline in language functioning after entering the OR. Tumor grade and the presence of preoperative language deficits were significant risk factors for this phenomenon, suggesting a possible relation between cognitive reserve, psychobehavioral coping abilities and histologic features of a tumor involving language areas. Capturing and identifying this unique population of patients who are prone to experience such language decline may improve our ability in the future to select patients eligible for awake-craniotomy.

Objective Surgical resection of posterior fossa metastases (PFM) includes either suboccipital craniotomy or suboccipital craniectomy. The optimal surgical technique is yet to be defined. We examined the association between the chosen surgical approach and the occurrence of postoperative complications. Methods We retrospectively evaluated medical records and imaging characteristics of patients who underwent resection of newly diagnosed PFM between 2003 and 2014 in our medical center to identify covariates that significantly affected postoperative complications. Results Of 917 patients with brain metastases, 88 patients underwent surgery for PFM and were included in the study. Craniectomy was performed in 54 cases (61%). Urgent postoperative posterior fossa decompression or cerebrospinal fluid diversion was performed in 4 patients (4.5%). Postoperative complications included postoperative central nervous system infection ( n = 10 [12%]), cerebrospinal fluid leak ( n = 3 [4%]), wound dehiscence ( n = 6 [7%]), and long-term pseudomeningocele ( n = 12 [14%]). The perioperative mortality rate was 2.3% ( n = 2). Multivariate analysis that included patient baseline characteristics, imaging study parameters, and surgical approaches demonstrated that suboccipital craniectomy was associated with more postoperative complications ( P = 0.03, odds ratio = 4.48, 95% confidence interval = 1.14–17.6). There was no correlation between patient baseline characteristics or surgical technique with the need for urgent postoperative posterior fossa decompression or cerebrospinal fluid diversion. Conclusions Suboccipital craniotomy may be associated with a lower incidence of postoperative morbidity compared with suboccipital craniectomy and should be considered as the preferred approach for the resection of PFM.

rain metastases are the most common brain tumor, accounting for 20%e48% of tumors in the brain (2). Brain B metastases occur in 20%e40% of patients with systemic cancer, and reported frequencies have increased in recent years (10). The most common primary tumors for brain metastases are lung cancer (40%e50%), breast cancer (15%e25%), and melanoma (5%e25%) (1). The primary site remains unknown in 15%of patients with brain metastases (10).

Background The posterior fossa is the site of many types of tumors, and brain metastases are the most common malignancies in that location among adults. Other brain tumors, such as ependymomas, medulloblastomas, and juvenile pilocytic astrocytomas, mostly occur during childhood and are relatively rare in adults. Most primary malignant brain tumors, such as gliomas and lymphomas, tend to be located in the supratentorial compartment. Methods This review summarizes prognostic factors, therapeutic management, and molecular data of intra-axial posterior fossa tumors in adults, including ependymomas, medulloblastomas, and pilocytic astrocytomas. Results The literature on intra-axial posterior fossa tumors in adults relies mainly on limited retrospective clinical studies, and such studies employ a wide range of treatment approaches that are usually based on therapies developed specifically for children or for supratentorial brain tumors. Conclusions The clinical course and surgical outcome of adult patients with intra-axial brain tumors in the posterior fossa are summarized in this review. The prognostic factors and therapeutic management of patients with these tumors are controversial because of their rarity, their heterogeneity, and the lack of sufficient data in the literature.

Dysphagia is a swallowing dysfunction and a known complication after posterior fossa surgery. It may lead to aspiration, dehydration, and malnutrition, all lifethreatening complications. Swallowing is a complex process that is activated in several phases, each involving both sensory and motor fibers. To understand the implications of dysphagia, we will briefly review the anatomy and physiology of the swallowing process. The first phase is the oral preparatory stage, or food mastication starting after the food is introduced into the mouth. This stage involves the trigeminal nerve that innervates the mastication muscles, the facial nerve that innervates the labial and buccinator muscles, and the hypoglossal nerve that innervates the tongue to move the food to the posterior teeth. This is followed by the oral stage, when the food is moved to the posterior part of the oral cavity, mainly controlled by the tongue (hypoglossal nerve). The third part is the pharyngeal stage, a reflex action that transports the food through the pharynx to the esophagus, but not to the nasopharynx or larynx that should be closed, thus protecting the airway from aspiration (mediated by cranial nerves IXeXI). The esophageal stage is a reflexive stage that transports the food by the esophageal peristaltic movement and relaxation of the lower esophageal sphincter (again, mediated by cranial nerves IXeXI). The posterior fossa is a small region containing the brain stem, cerebellum, and fourth ventricle and controls many vital functions, such as speech, hearing, movement, sensation, and swallowing. Expansion of a mass in the posterior fossa occurs at the expense of the normal structures in the region and may result in brain stem or cerebellar dysfunction. Less than 5% of all adult tumors originate in the posterior fossa, whereas approximately 50% of primary central nervous system tumors occurring in

Background Metastatic tumors involving the pituitary gland are very rare, with only few cases reported so far in the literature. Case Description We report a case of a man who presented with an extremely vascular hemorrhagic pituitary metastasis as the first manifestation of renal cell carcinoma. The patient was successfully treated with staged procedures, including preoperative tumor vasculature embolization followed by transsphenoidal tumor resection. Conclusions This is the first report describing multimodality treatment of a patient with pituitary metastasis of unknown origin requiring presurgical embolization before successful tumor removal.