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Today, stereotactic radiosurgery is an effective therapy for a variety of intracranial pathology that were treated solely with open neurosurgery in the past. The technique was developed from the combination of therapeutic radiation and stereotactic devices for the precise localization of intracranial targets. Although stereotactic radiosurgery was originally performed as a partnership between neurosurgeons and radiation oncologists, this partnership has weakened in recent years, with some procedures being performed without neurosurgeons. At the same time, neurosurgeons across the United States and Canada have found their stereotactic radiosurgery training during residency inadequate. Although neurosurgeons, residency directors, and department chairs agree that stereotactic radiosurgery education and exposure during neurosurgery training could be improved, a limited number of resources exist for this kind of education. This review describes the history of stereotactic radiosurgery, assesses the state of its use and education today, and provides recommendations for the improvement of neurosurgical education in stereotactic radiosurgery for the future.

Objective Neurofibromatosis type 2 (NF2) is an autosomal dominant disease characterized by bilateral vestibular schwannomas (VSs). NF2-associated VSs (NF2-VSs) are routinely treated with microsurgery; however, stereotactic radiosurgery (SRS) has emerged as an effective alternative in recent decades. To elucidate the role of SRS in NF2-VSs, a systematic review of the literature was conducted to compare outcomes of SRS versus surgery. Methods PubMed, Web of Science, Scopus, Embase, and Cochrane databases were queried using relevant search terms. Retrospective studies investigating outcomes of NF2-VS patients treated with either SRS or surgery were included. Single-patient case reports were excluded. Outcome measures between the SRS and surgery groups were compared using χ 2 2-sample tests for equality of proportions on the pooled patient data. Results A total of 974 patients (485 SRS, 489 surgery) were identified. The mean 5-year local control rate for SRS was 75.1%, and the mean recurrence rate for surgery was 8.1%. The mean hearing and facial nerve preservation rates were 40.1% and 92.3%, respectively, for SRS and 52.0% and 75.7%, respectively, for surgery. Rates of hearing preservation were higher after surgery than after SRS ( P = 0.006), whereas rates of facial nerve preservation were higher after SRS than after surgery ( P Conclusions SRS appears to be a safe and effective alternative to surgery for NF2-VS. Although rates of hearing preservation were higher in the surgery cohorts, SRS demonstrated high rates of local control and significantly lower facial nerve complications. Certain patients may therefore benefit more from SRS than surgery.

Epithelial membrane protein 2 (EMP2) is a cell surface protein that has recently emerged as an object of neuro-oncological interest due to its potential to be utilized as a biomarker and target for antibody therapies. Preclinical studies have demonstrated that EMP2 is associated with disease prognosis in a number of human cancers, including glioblastoma. The four large extracellular domains of EMP2 and its association with the extracellular matrix makes it an attractive target for future cancer therapies. Translational research suggests that EMP2 may be targeted with antibodies to improve tumor control and survival in a variety of murine models and cancer types. However, in order to translate these preclinical findings into the clinic, future research will need to focus on elucidating the role EMP2 in the normal human body by better understanding its molecular and chemical interactions. The focus of this review is to provide a comprehensive insight into current research endeavors, discuss the potential for clinically translatable applications, and predict the future directions of such research.

Superior semicircular canal dehiscence (SSCD) is a rare defect of the arcuate eminence that causes an abnormal connection between the superior semicircular canal and middle cranial fossa. Patients often present with a variety of auditory and vestibular symptoms. Trigger avoidance is the initial strategy, but surgery may be necessary in debilitating cases. We retrospectively reviewed SSCD patients undergoing repair via a middle fossa craniotomy between March 2011 and September 2015. Forty-nine patients undergoing 58 surgeries were identified. Autophony was the most common symptom at presentation (n=44; 90%). Mean follow-up was 10.9months, with 100% of patients reporting resolution of at least one symptom. Aural fullness was the most commonly resolved symptom following surgical repair (n=19/22; 86%). Hearing loss (n=11/25; 44%) and tinnitus (n=11/38; 29%) were the most common symptoms to persist following surgery. The most common symptom to develop after surgery was disequilibrium (n=4/18; 22%). Upon comparing the overall pre-operative and post-operative groups, the number of patients with autophony (p

To present an illustrative case of fourth ventricular epidermoid cyst and review the literature to identify predictors of surgical outcomes.A case of fourth ventricular epidermoid cyst is presented and a systematic review of 5 popular databases was performed by independent authors. Stepwise logistic regression was performed to identify clinical predictors of outcomes.A 21-year-old woman presented with 3 months of headaches and visual obscurations and was diagnosed with a multilobulated mass in the fourth ventricle. The patient underwent suboccipital craniotomy. Complete removal of the mass was achieved and the final diagnosis was consistent with an epidermoid cyst. The systematic review identified 23 studies that reported 37 patients. Mean age was 42.8 years. Mean length of time between symptom onset and diagnosis was 4.43 years. Age (P = 0.049) and duration of symptoms (P0.001) were significantly different between patients who experienced symptom improvement and those who did not. Duration of symptom onset to diagnosis was a significant predictor of poor outcomes (odds ratio, 1.19, 95% confidence interval, 1.003-4.785).Our review found that in patients with fourth ventricular epidermoid cysts, unfavorable outcomes were predicted by older age and by longer intervals from symptom onset to diagnosis. Clinicians should maintain a high index of suspicion for fourth ventricular epidermoid cysts in patients presenting with cerebellar signs and visual disturbances.

To assess the utility of frequent sodium checks (every 6h) in patients receiving hypertonic saline (HS) after elective brain tumor surgeries.A single-institution retrospective review of patients having undergone elective craniotomies for brain tumors and treated with postoperative continuous intravenous infusions of 3% HS was performed. Changes in serum sodium values were analyzed at different time points. The rates of12.5, 25, and 50cc/h infusions were also examined. Healthcare cost analysis was performed by extrapolating our cohort to the total number of craniotomies performed in the United States.No significant differences among sodium values checked between 0 to 4, 4-6, 6-8, 8-10, and10h were observed (P=.64). In addition, no differences in serum sodium values among the rates of12.5, 25, and 50cc/h were found (P=.30). No patients developed symptoms of acute hypernatremia.Serum sodium values did not significantly change more than 10h after infusion of HS. Further studies are needed to determine the optimal frequency of routine sodium checks to increase the quality of care and decrease healthcare costs.

Chemokine (C-C) motif ligand 21 (CCL21) is involved in immunosurveillance and has recently garnered the attention of neuro-oncologists and neuroscientists. CCL21 contains an extended C-terminus, which increases binding to lymphatic glycosaminoglycans and provides a mechanism for cell trafficking by forming a stationary chemokine concentration gradient that allows cell migration via haptotaxis. CCL21 is expressed by endothelial cells of the blood-brain barrier in physiologic and pathologic conditions. CCL21 has also been implicated in leukocyte extravasation into the central nervous system. In this review, we summarize the role of CCL21 in immunosurveillance and explore its potential as an immunotherapeutic agent for the treatment of gliomas.

Pineal germ cell tumors (GCTs) are primarily seen in pediatric and Asian populations. These tumors are divided into germinomatous and non-germinomatous GCTs (NGGCTs). GCTs are thought to arise by misplacement of totipotent stem cells en route to gonads during embryogenesis. Intracranial GCTs display an affinity to develop along the pineal-suprasellar axis and have variable manifestations dependent upon the location of the tumor. Management and outcomes are driven by histopathologies. In this study, we highlight two cases of pineal GCTs and present a review of the literature with an emphasis on histopathologies and biomarkers.

Objective To review the literature on isolated transverse process fractures (ITPFs) and provide evidence for the current practice of conservative management. Methods The PubMed database was searched for published literature related to ITPFs. Baseline patient (age, sex, presentation, and mechanism of injury) and fracture (number of fractures, level, and single or multisegmental) characteristics were extracted. Management and outcomes were also recorded. Statistical comparisons were ascertained through n–1 Pearson χ 2 tests. Results A total of 4 studies comprised of 398 patients with 819 ITPFs were evaluated. Mean age was 33.5 years (69% men and 31% women). No patients presented with neurologic deficits. The most common mechanism of injury was motor vehicle accident (MVA), followed by fall. MVAs were more commonly the cause of ITPFs in pediatric versus adult patients (88% vs. 65%, respectively; P = 0.0001). Falls were more commonly the cause of ITPFs in adults than in children (18% vs. 9%, respectively; P = 0.05). Management strategies involved unrestricted movement, bracing, and orthotics. Radiologic evidence of spinal instability or deformity was not reported in any of the cases. Mean follow-up was 20.5 months. Conclusions Our data suggests that nonsurgical management of ITPFs leads to complete resolution of the fracture without evidence of permanent neurologic deficit or spinal instability. However, interpretation of our results is limited by the paucity of meaningful literature reporting on long-term outcomes. Nevertheless, the results provide support for conservative management and highlight the existing need to identify markers or scenarios where the diagnosis of ITPF is actually likely to be erroneous.

Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a novel minimally invasive modality that uses heat from laser probes to destroy tissue. Advances in probe design, cooling mechanisms, and real-time MR thermography have increased laser utilization in neurosurgery. The authors perform a systematic analysis of two commercially available MRgLITT systems used in neurosurgery: the Visualase® thermal therapy and NeuroBlate® Systems. Data extraction was performed in a blinded fashion. Twenty-two articles were included in the quantitative synthesis. A total of 223 patients were identified with the majority having undergone treatment with Visualase (n=154, 69%). Epilepsy was the most common indication for Visualase therapy (n=8 studies, 47%). Brain mass was the most common indication for NeuroBlate therapy (n=3 studies, 60%). There were no significant differences, except in age, wherein the NeuroBlate group was nearly twice as old as the Visualase group (p

Neurosurgery has undergone a technological revolution over the past several decades, from trephination to image-guided navigation. Advancements in virtual reality (VR) and augmented reality (AR) represent some of the newest modalities being integrated into neurosurgical practice and resident education. In this review, we present a historical perspective of the development of VR and AR technologies, analyze its current uses, and discuss its emerging applications in the field of neurosurgery.

Purpose This work describes trends in the utilization and survival benefit of stereotactic radiosurgery (SRS) with respect to geographic region of the United States and year of diagnosis among patients with NSCLC and synchronous brain metastases. Methods Patients with NSCLC and synchronous brain metastases (2010–2015) were identified in the NCDB. Descriptive statistics were calculated across case SRS utilization and geographic region. Univariable and multivariable regression were performed to identify predictors of SRS treatment in the overall population and to estimate geographic region-specific models of SRS utilization and hazard of mortality over each year. Results Among the 49,048 cases of NSCLC with synchronous brain metastases, 8310 were treated with SRS. Those in the Middle Atlantic had the greatest odds of SRS treatment, at 1.03 times those of patients in the East North Central (95% CI: 1.02–1.04, p Conclusion Increased utilization of SRS was observed with decreased hazard of mortality over five diagnosis-years among NSCLC patients with synchronous brain metastases. These trends suggest the clinical burden of secondary cancers, particularly brain metastases, will increase in the years to come.

Objective : To investigate if delay of adjuvant radiotherapy (ART) beyond 6 post-operative weeks affects survival outcomes in patients undergoing craniotomy or craniectomy for resection of non-small cell lung cancer (NSCLC) intracranial metastases. Patients and methods We performed a retrospective analysis of 28 patients undergoing resection of intracranial metastases and ART at our institution from 2001 to 2016. We assessed survival outcomes for patients who received delayed versus non-delayed ART, as well as associated risk factors. Results Among 28 patients, 8 (29%) had delayed ART beyond 6 post-operative weeks. Fifteen received stereotactic radiotherapy (SRT), 8 (29%) received whole brain radiotherapy (WBRT), and 5 (18%) received combination WBRT + SRT. There were no significant differences in ART modality or dosing, age, sex, number of intracranial metastases, primary metastasis volume, rates of chemotherapy, extracranial metastases, or post-operative functional scores between groups. Expected post-operative survival was shorter with delayed ART (7 months versus 28 months, P = 0.01). The most common reason for delayed ART was complicated post-operative course (n = 3.38%). Significant risk factors for delayed ART included non-routine discharge (P = 0.01) and additional invasive procedures between surgery and ART start date (P = 0.02). Conclusions Our results suggest delayed ART in patients undergoing surgical resection of intracranial NSCLC metastases is associated with shorter overall survival. However, risk factors for delayed ART, including non-routine discharge and the need for additional invasive procedures, may have in themselves reflected poorer clinical courses that may have also contributed to the observed survival differences.

Objective: To assess the frequency of physician business card utilization among neurosurgery residents and its impact on patient satisfaction, reflected in scores on the CI-CARE patient survey. The authors hypothesize that neurosurgeons hand out business cards less frequently and that this may have potential implications for patient satisfaction. Methods: A retrospective review of patient survey results was performed. Residents were divided into two groups: 1) business card use and 2) no business card use. Scores on survey questions, which pertained to overall communication, medical expertise, and quality of care delivered were compared between groups using a Mann-Whitney U test. Results: A total of 4222 surveys of 367 residents across 9 departments were collected. PGY-1 and -2 residents were most frequently evaluated (n = 1647, 39% and n = 1416, 33.5%, respectively) and handed out the most business cards (n = 398, 25.4% and n = 302, 22%, respectively). PGY-1 and -2 residents who handed out business cards were perceived by patients to be better overall communicators and have greater medical expertise (P