Search

INTRODUCTION Until recent decades, thalamic gliomas had been considered largely inoperable. These lesions are deep-seated and surrounded by vital structures. However, as technology and imaging modalities have improved, so have treatment modalities. Currently, a range of surgical approaches are used, partially dependent on the location of the lesion; although no consensus has been reached regarding optimal surgical management. OBJECTIVE To conduct a systematic review of the literature to describe the current surgical outcomes of adult thalamic gliomas. METHODS Four databases were searched with keywords “‘thalamic glioma’ AND ‘surgical intervention’ OR ‘thalamic glioma’ AND ‘surgical treatment’” for articles assessing surgical techniques of adult thalamic glioma resection. Our systematic review was reported in accordance with the PRISMA guidelines. 793 full-text studies were assessed for eligibility. Ultimately, 14 studies were included. RESULTS The mean age was of 33.57 years (18-83). In 479/507 cases the surgical strategy used was described. The transcortical approach was the most utilized (37.8% of cases). The remaining cases employed transventricular (23.8%), transcallosal (22.8%), and trans-sylvian transinsular (2.92%) approaches, among others. Gross total resection (GTR), subtotal resection (STR), and partial resection were achieved in 36.7%, 47.4%, and 15.9%, respectively. New temporary postoperative deficits were observed in 57/507 patients and new permanent deficits in 56/507 patients. There were 18 total perioperative deaths reported. The degree of morbidity across approaches was recorded in just one study, where no significant difference was found. The mean overall survival of adult patients after surgery ranged from 11.5 to 27.39 months across studies. CONCLUSION There is a lack of statistically strong data that addresses which surgical approach causes less morbidity and allows a better surgical resection for thalamic gliomas. Ultimately, surgical resection of adult thalamic gliomas can increase overall survival but at the risk of operative morbidity. Transcortical approaches appear to carry a greater overall survival

INTRODUCTION Adult midline gliomas are rare entities, with a scarcity of available clinical data. These patients have variable courses, with limited evidence to predict outcomes. Emerging evidence suggests that biomolecular profiles may play a significant role in outcomes, so tissue diagnosis is a key component of management. However, the role of cytoreductive therapy, such as Laser Interstitial Thermal Therapy (LITT) remains unknown. To date, only a few studies have described the use of MRI-guided LITT for managing midline gliomas. OBJECTIVE To present a retrospective analysis of a single-center two-surgeon experience treating adult midline gliomas with either biopsy/LITT or biopsy alone. METHODS Patients with midline intraxial tumors surgically treated at our tertiary care referral center were identified using our established database. Twenty-one patients managed either with biopsy/LITT or needle biopsy from 2015 to 2021 were included. Demographics and clinical records including, among others, length of hospital stay, preoperative lesion size, ablation volume, perioperative complications, adjuvant treatment, and stratified overall survival (OS) were collected. RESULTS The two cohorts were composed of 7 patients who underwent LITT, and 14 biopsies. The mean age was 60.95y (25-82). The average tumor volumes were 16.99 cm3 and 15.41 cm3 for LITT and biopsy, respectively. No post-surgical complications were found in the LITT group, one patient had a postsurgical hemorrhage after biopsy. The mean OS was 20.28 ± 9.63 months in the LITT group, which was greater but not statistically significant than in the biopsy group (11.05 ± 4.45 months) (p = 0.605). CONCLUSION Our results show that LITT is as safe as needle biopsy for the treatment of adult midline gliomas, and may offer a survival benefit given its cytoreductive properties.

INTRODUCTION Ovarian cancer is a rare cause of brain metastasis requiring neurosurgical intervention. Management strategies vary and prognostic factors are not well known. OBJECTIVE We aim to systematically review the literature on management and outcomes of ovarian cancer brain metastasis and compare it with our experience. METHODS Systematic review was performed using PRISMA guidelines. Databases were sourced from inception to April 2022. Study selection was based on predetermined inclusion/exclusion criteria. A simultaneous retrospective analysis was performed on patients from our institution who underwent evaluation and treatment for metastatic intracranial lesions of ovarian origin. RESULTS Literature search generated 214 articles. Twelve were ultimately selected, representing 428 brain metastasis (BM) patients from ovarian cancer. Patients age from 27-80 years. The interval from cancer diagnosis to BM ranged from 0 – 226.2 months. Surgical resection (SR), stereotactic radiosurgery (SRS), and whole-brain radiotherapy were the most frequently used treatment modalities. Individual patients’ overall survival following BM diagnosis ranged from 0 – 173 months. For our institutional analysis, 9 patients were included with median age of 56 years. Median interval from diagnosis to BM was 51 months. Four patients were treated with SR and adjuvant SRS. Two patients had SR and SRS with additional extraventricular drain placement. Two patients had SR only, and one received only SRS. Median radiation dose received was 20 Gy. For those who experienced progression, median progression-free survival was 14 months. One patient exhibited no progression at the time of analysis. Three patients were alive at the time of analysis with two others lost to follow-up. CONCLUSION brain metastases following ovarian cancer are a rare outcome carrying a poor prognosis. Multimodal therapies, specifically SR and SRS, correlate with increased survival. Further study is needed to better guide optimal management, with particular attention to the benefits of resection with targeted adjuvant radiation.

BACKGROUND There is a need to evaluate the outcomes of patients who underwent brain tumor surgery and were followed by telemedicine or in-person consults during the COVID-19 pandemic. METHODS We retrospectively included all patients who underwent surgery for brain tumor resection by a single neurosurgeon at our Institution from the beginning of the COVID-19 pandemic restrictions (March 2020) to August 2021. Outcomes were assessed by stratifying the patients using their preference for follow-up method (telemedicine or in-person). RESULTS Three-hundred and eighteen (318) brain tumor patients who were included. The follow-up method of choice was telemedicine in 185 patients (58.17%), and in-person consults in 133 patients. We found that patients followed by telemedicine lived significantly farther, with a median of 22.23 miles, compared to a median of 36.34 miles in the TM cohort (p = 0.0025). When comparing visits to the emergency department (ED) within 30 days after surgery, and we found no statistical difference between the TM and the IP group (7.3% vs 6.01%, p=0.72). Readmission rates, wound infections and 30-day mortality were similar in both cohorts. These findings were also consistent after matching cohorts using a propensity score. The percentage of telemedicine follow-up consults was higher in the first semester (73.17%) of the COVID-19 pandemic, compared to the second (46.21%) and third semesters (47.86%). CONCLUSIONS Telehealth follow-up alternatives may be safely offered to patients after brain tumor surgery, thereby reducing patient burden in those with longer distances to the hospital or special situations as the COVID-19 pandemic.

INTRODUCTION Cranial neurosurgery confers psychological stress, as well as the stress of being in the hospital rather than in one’s preferred surroundings. Compared with inpatient admissions, same-day discharges reduce patient exposure to nosocomial infection, thromboembolic complications, and medical error. Also, it reduces costs to the health care system. OBJECTIVE To report the results of a pilot study that prospectively evaluated for the first time in a United States hospital, the outcomes of patients that underwent brain tumor surgery and are discharged home the same day as surgery. METHODS A quality intervention study including patients who underwent outpatient craniotomy for brain tumors by a single neurosurgeon (R.J.K) at the University of Miami from August 2020 to August 2021 was performed. Patients included were between 16 to 85 years old, with a Karnofsky Performance Status score of ≥ 70, and with supratentorial tumors with a maximum diameter of 4 cm. Complete demographic and clinical data were collected prospectively for each patient. In all patients, the minimum observation period was 6 h after surgery. RESULTS 37 of 334 patients met the inclusion criteria for the outpatient protocol. Thirty-two patients were discharged on the same day as surgery. Five patients (14%) were considered eligible for outpatient surgery but were ultimately admitted to the hospital postoperatively and were discharged after overnight observation. No postoperative complications were noted at two-week follow-up. CONCLUSION With appropriate selection and postoperative monitoring, same-day discharge can be considered a safe and feasible option for certain craniotomy cases. Establishing a multidisciplinary team of physicians, nurses, radiologists, and physical therapists is critical to achieving this aim. Physicians should have a low threshold to admit a patient with concerning exam findings, complications, or complicated past medical history

INTRODUCTION Classical prefrontal approaches exposed the lateral surface of the frontal lobe. Minimally invasive (MI) approaches achieved to reduce soft tissue damage and craniotomy size without affecting tumor resection grade. This is associated with shorter hospital stays and faster return to preoperative daily activities. OBJECTIVE To describe the MI prefrontal glioma resection technique developed in our department and to analyze our surgical results. METHODS We performed a retrospective review of patients who underwent prefrontal lobe glioma (WHO grade II-IV) resection using an MI approach in 2016-2021 at the University of Miami Hospital. Re-surgery, biopsy-only patients, multicentric tumors, and patients with less than four months of follow-up were excluded. Demographic and clinical data were collected. A 4-5 cm linear incision is done, starting at 1 cm lateral to the sagittal suture and extending towards the superior temporal line. An ellipsoidal-shaped mini-craniotomy is performed. RESULTS Thirty-four patients were included. The mean age was 50.2 years old, with 20 male subjects. Twenty-two patients had high-grade gliomas (HGG) and 12 patients had low-grade gliomas (LGG). On average, patients were discharged 1.97 days after surgery. The mean craniotomy area was 15,5 cm2 (7-43 cm2). The mean tumor volume was 64,5 cm2 ( 9 -165.8 cm2). Two wound infections and one case of aseptic meningitis were observed in patients with craniotomies > 15 cm2, while the group with craniotomies < 15 cm2 had no perioperative complications. In the HGG group, a supramaximal resection (SMR) was achieved in 8 patients, 9 HGG patients had gross total resection (GTR) or near-total resection (NTR), and 5 patients had subtotal resection (STR). In the LGG, GTR was achieved in 10 patients and STR in 2 patients. CONCLUSION MI prefrontal approach for frontal gliomas is safe and feasible with minor complications, short hospital stay, and without sacrificing tumor resection volume.

INTRODUCTION The concept of enhanced recovery after surgery (ERAS) due to standardized interventions has been gaining more relevance within neurosurgery. Advances were made both in protocols for spine and cranial surgery. These experiences described many benefits such as less psychological stress, reduction in hospitalization days, and lower hospital costs, without increasing the incidence of complications. However, no experience has described to date the applicability of an ERAS program for laser ablation thermal therapy (LITT). OBJECTIVE To describe our initial experience with the first enhanced recovery program reported for laser ablation for brain tumors. Secondly, to summarize the perioperative clinical outcomes of ERAS applied to LITT. METHODS We performed a retrospective analysis of all adult patients who underwent LITT for oncological lesions from 2013 to 2021. A multidisciplinary program was created by protocolizing interventions carried out along the path of the patient's hospitalization. Each recommendation was individually assessed for its appropriateness for enhancing recovery and for its validity with a focused literature review process. RESULTS A total of 184 patients were included, with a mean age of 60.7 ± 13.5 years, 35% males. 167 tumors were located in the supratentorial compartment, and 17 were infratentorial; the mean tumor diameter was 1.84 ± 1.04 cm. Among the pathologies treated 50.0% were metastasis, and 36.9% were glioblastomas. The mean postoperative day discharge was 1.2 ± 0.8 days. The readmission rate due to surgical complications within 30 days of surgery was 2.7%. These readmission rates fall into what is expected according to published literature without an ERAS program and longer hospital admissions. One death was recorded in the perioperative period. CONCLUSION Clinical interventions that could constitute an ERAS program are feasible in laser ablation of brain tumors. This study could be useful as a preliminary framework for the development of future guidelines.

To model low-grade astrocytoma (LGA) formation, we introduced R132H IDH1, P53 shRNA and ATRX shRNA in human neural stem cells (NSCs). These oncogenic hits blocked NSC differentiation, increased invasiveness in vivo and led to an epigenetic and transcriptional profile resembling IDH1-mutant human LGAs. The differentiation block was caused by transcriptional silencing of transcription factor SOX2. Ectopic expression of SOX2 was sufficient to rescue the differentiation block. We found that SOX2 down-regulation was secondary to disassociation of its promoter from a putative long-range enhancer ~700kb downstream of SOX2. This occurred due to reduced binding of the chromatin organizer CTCF to its methylated DNA motifs and disrupted chromatin looping. Our human model of IDH-mutant LGA implicates impaired NSC differentiation due to epigenetic repression of SOX2 as an early driver of gliomagenesis.

Background: Previous reports have proposed an association between traumatic brain injury (TBI) and subsequent glioblastoma (GBM) formation. Methods: We used literature searches and radiographic evidence from two patients to assess the possibility of a link between TBI and GBM. Results: Epidemiological studies are equivocal on a possible link between brain trauma and increased risk of malignant glioma formation. We present two case reports of patients with GBM arising at the site of prior brain injury. Conclusion: The hypothesis that TBI may predispose to gliomagenesis is disputed by several large-scale epidemiological studies, but supported by some. Radiographic evidence from two cases presented here suggest that GBM formed at the site of brain injury. We propose a putative pathogenesis model that connects post-traumatic inflammation, stem and progenitor cell transformation, and gliomagenesis.