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Craniopharyngiomas involving the ventricular system are rare but pose significant surgical challenges. We systematically reviewed the literature on craniopharyngiomas invading the ventricles (CP-V).PubMed, EMBASE, Scopus, Web of Science, and Cochrane were searched to include studies reporting clinical data of patients with CP-Vs. Clinico-radiological features, management, and treatment outcomes were analyzed.We included 73 studies encompassing 407 patients. Patients were mostly male (61.5%), presenting with headache (57.9%) and/or endocrine disorders (52.1%). CP-Vs mostly involved the third ventricle (96.3%), followed by the lateral ventricles (2.9%), and the fourth ventricle (1%). Tumors had cystic components in 59% of cases and were mostly adamantinomatous (70.8%). Open resection was performed in 232 cases (57%), mostly with trans-lamina terminalis (36.6%) and trans-callosal (31.9%) approaches. Endoscopic resection was performed in 169 cases (41.5%), mostly with trans-sphenoidal (74.6%) and transventricular (24.9%) approaches. Gross-total tumor resection was obtained in most cases (62.9%). Adjuvant radiotherapy was delivered in 22.8% cases. A total of 178 patients experienced persistent complications, mostly including diabetes insipidus (47.1%) and panhypopituitarism (12.7%), not significantly different after open versus endoscopic resection (p=0.117). Symptom improvement was obtained in 88% of cases. CP-Vs recurrences were reported in 94 patients (23.1%), with median progression-free survival of 13.5 months (range=0.5-252.0 months). Fifty-nine patients died (14.5%), with median overall survival of 32.0 months (range=0.5-252.0 months), significantly longer after endoscopic resection than open resection (p=0.019).CP-Vs are uncommon and challenging entities. Surgical resection is feasible, but patient-tailored selection of open/endoscopic approaches is necessary to achieve optimal outcomes and minimize complication risks.

Intradural extramedullary spinal metastases (IESMs) may severely affect quality-of-life of oncological patients. Several treatments are available but their impact on prognosis is unclear. We systematically reviewed the literature on IESMs of non-neurogenic origin.PubMed, Ovid EMBASE, Scopus, and Web-of-Science were screened to include articles reporting patients with IESMs from non-neurogenic primary tumors. Clinico-radiological presentation, treatments, and outcomes were analyzed.We included 51 articles encompassing 130 patients of a median age of 62 years (range=32-91 years). The most common primary neoplasms were pulmonary (26.2%), renal (20%), and breast (13.8%) carcinomas. Median time interval from primary tumor to IESMs was 18 months (range=0-240 months). The most common symptoms were sensory (58.3%) and motor (54.2%) deficits. Acute cauda equina syndrome was reported in 29 patients (37.7%). Lesions were diagnosed at magnetic resonance imaging (93.3%), myelography (25%), or computed tomography (16.7%). All patients underwent decompressive laminectomy with tumor resection, partial (54.6%) more frequently than complete (43.1%). Adjuvant radiation (67.5%) and/or systemic (13.3%) therapies were administered. After treatment, most patients had symptom improvement (70.8%) and optimal radiological response (64.2%). Four patients experienced IESMs recurrences (3.1%) with median local tumor control of 14.5 months (range=0.1-36 months). Deaths occurred in 50% of patients, with median overall survival of 6.7 months (range=0.1-108 months).Patients with IESMs have significant tumor burden with poor prognoses. Resection and locoregional radiation may offer favorable clinico-radiological responses but are limited in achieving optimal local control and survival.

Background The optimal management of patients with acute ischemic stroke (AIS) due to tandem occlusion (TO) and underlying carotid dissection (CD) remains unclear. Objective We present our multicenter-experience of endovascular treatment (EVT) approach used and outcomes for AIS patients with CD-related TO (CD-TO). Methods Consecutive AIS patients underwent EVT for CD-TO at five Italian Neuro-interventional Tertiary Stroke Centers were retrospectively identified. TO from atherosclerosis and other causes of, were excluded from the final analysis. Primary outcome was successful (mTICI 2b-3) and complete reperfusion (mTICI 3); secondary outcome was patients’ 3-months functional independence (mRS≤2). Results Among 214 AIS patients with TO, 45 presented CD-TO. Median age was 54 years (range 29–86), 82.2% were male. Age Conclusion AIS patients with CD-TO were mostly treated with the retrograde approach with lower number of attempts per-procedure but it offered similar recanalization rates compared with the antegrade approach. Emergent carotid artery stenting (CAS) proved to be safe for CD management but it does not influence 3-months patients’ clinical outcomes.

Extraventricular supratentorial ependymomas are rare entities. Most ependymomas are located at the infratentorial and intraventricular level, and only in a small group of cases they do not present continuity with the ventricular system. This is a case report of a patient with an atypical location of a cerebral ependymoma, which required the implementation of a complex and infrequent approach for its complete microsurgical removal.A 16-year-old male patient was referred at our department with a diagnosis of a 40 mm × 50 mm × 60 mm solid-cystic space-occupying lesion, sited between the left superior frontal-cingulate gyri. A contralateral transfalcine interhemispheric approach was selected, which achieved total resection of the tumor. The histopathological diagnosis of Grade II ependymoma was obtained according to WHO classification.The contralateral transfalcine interhemispheric approach represents a favorable surgical corridor to achieve a total resection of the tumor lesion and is favored by an adequate working angle and reduced brain manipulation.

Intradural cauda equina metastases (ICEM) are rare tumors that reduce functional status. Surgery and radiation are feasible and effective treatments but may have debilitating complications. We systematically reviewed the literature on ICEMs.PubMed, Scopus, Web of Science, and Cochrane were searched for studies reporting clinical data of patients with ICEMs. Clinical characteristics, management strategies, and treatment outcomes were analyzed.We included 40 studies comprising 123 patients. Median age was 57 years. The most frequent primary tumors were lung (18.7%), breast (13%), and renal carcinomas (11.4%). Median time from primary tumor diagnosis to ICEMs' presentation was 36 months. The most common presenting symptoms were lower back pain (74%) and motor deficits (62.6%), with acute cauda equina syndrome documented in 36 patients (29.3%). Most lesions were diagnosed at magnetic resonance imaging (56.9%) or computed tomography myelography (32.5%). All cases were treated with decompressive laminectomy and tumor resection, with partial resection (82.1%) more often than complete (15.4%). Adjuvant radiotherapy (83.7%) and/or chemotherapy (10.6%) were often administered. Most patients experienced post-treatment symptom improvement (86.2%) and favorable radiological response (82.9%). ICEM recurrences were reported in 4 cases (8.5%) with median local tumor control of 7 months. At last follow-up, most patients were dead (62.9%) with median overall-survival of 10 months.Patients with ICEMs have poor prognoses and significant tumor burden. Surgery and locoregional radiotherapy may offer optimal clinical and radiological outcomes but have a limited role in improving local tumor control and overall survival.

Simple Summary Orbital metastases may significantly worsen the functional status of oncological patients, leading to debilitating visual impairments. Surgical resection, orbital exenteration, and complementary therapies may result in heterogeneous clinical outcomes. In this systematic review, we aimed to comprehensively analyze the current literature on orbital metastases, describing clinical and imaging features, available management, and treatment outcomes. We found that most orbital metastases occur at later stages after primary tumors, frequently showing diffuse location within the orbit and rarely invading intracranial structures. Biopsy-only techniques were more frequently preferred in view of the less invasive approaches, but surgical resection and orbital radiotherapy were related to improved clinical outcomes. Although patients with primary breast cancer and patients undergoing resection showed superior prognoses, overall survival rates were generally poor, suggesting the need to better understand orbital metastases’ microenvironments for devising optimal systemic treatment strategies. Abstract Background: Orbital metastases often lead to severe functional impairment. The role of resection, orbital exenteration, and complementary treatments is still debated. We systematically reviewed the literature on orbital metastases. Methods: PubMed, Scopus, Web-of-Science, and Cochrane were searched upon PRISMA guidelines to identify studies on orbital metastases. Clinical characteristics, management strategies, and survival were analyzed. Results: We included 262 studies comprising 873 patients. Median age was 59 years. The most frequent primary tumors were breast (36.3%), melanoma (10.1%), and prostate (8.5%) cancers, with median time interval of 12 months (range, 0–420). The most common symptoms were proptosis (52.3%) and relative-afferent-pupillary-defect (38.7%). Most metastases showed a diffuse location within the orbit (19%), with preferential infiltration of orbital soft tissues (40.2%). In 47 cases (5.4%), tumors extended intracranially. Incisional biopsy (63.7%) was preferred over fine-needle aspiration (10.2%), with partial resection (16.6%) preferred over complete (9.5%). Orbital exenteration was pursued in 26 patients (3%). A total of 305 patients (39.4%) received chemotherapy, and 506 (58%) received orbital radiotherapy. Post-treatment symptom improvement was significantly superior after resection (p = 0.005) and orbital radiotherapy (p = 0.032). Mean follow-up was 14.3 months, and median overall survival was 6 months. Fifteen cases (1.7%) demonstrated recurrence with median local control of six months. Overall survival was statistically increased in patients with breast cancer (p < 0.001) and in patients undergoing resection (p = 0.024) but was not correlated with orbital location (p = 0.174), intracranial extension (p = 0.073), biopsy approach (p = 0.344), extent-of-resection (p = 0.429), or orbital exenteration (p = 0.153). Conclusions: Orbital metastases severely impair patient quality of life. Surgical resection safely provides symptom and survival benefit compared to biopsy, while orbital radiotherapy significantly improves symptoms compared to not receiving radiotherapy.

Essential tremor (ET) may severely impact patient's Quality of Life. Several techniques such as radiofrequency, deep brain stimulation (DBS), gamma knife (GK) radiosurgery and high-intensity focused ultrasound may be used for the surgical treatment of ET. The aim of this paper is to summarize the most recent available literature on DBS, transcranial magnetic resonance-guided focused ultrasound (tcMRgFUS) and GK, and to compare indications, targets, and effectiveness of these surgical techniques for the treatment of ET.A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The literature search was performed on the three largest medical databases (PubMed, Scopus, and Web of Science). This systematic review is focused on the effectiveness and safety of GK, DBS, and tcMRgFUS as functional neurosurgical techniques for the treatment of ET. The aim of this study was to compare these techniques by evaluating mode, target, effectiveness in improving motor outcomes, and rates of adverse effects.Articles meeting the predetermined criteria were included. Data for DBS, tcMRgFUS, and GK were analyzed and compared for indications, patient selection, advantages vs. disadvantages, and treatment targets for essential tremor.DBS, tcMRgFUS and GK are effective techniques for the treatment of ET. Despite different functioning principles, all three surgical techniques require a proper functional diagnosis to define accurate indications for patient selection. Their indication depends upon the patient's neurological condition and their effectiveness relies on proper targeting.

Parkinson disease (PD) has been recognized as responsible for concurrent spinal disorders. Surgical correction may be necessary, but the complexity of such fragile patients may require specific considerations. We systematically reviewed the literature on degenerative spine surgery in patients with PD.PubMed, Scopus, Web of Science, and Cochrane were searched according to the PRISMA guidelines to include studies reporting clinical data of patients with PD undergoing degenerative spine surgery. Clinical characteristics, treatment protocols, and outcomes were analyzed.We included 22 articles comprising 442 patients (61.5% female). Mean age was 66.9 ± 3.5 years (range, 41-83 years). Mean PD duration and modified Hoehn and Yahr stage were 4.46 ± 2.39 years and 2.3 ± 0.8, respectively. Operation types included fusion (55.3%) and decompression (41.6%). Mean operated spine levels were 6.0 ± 5.08. A total of 377 postoperative complications occurred in 34.6% patients, categorized into mechanical failure (58.0%), infection (15.1%), or neurologic (10.7%). Of patients, 31.8% required surgical revisions, with an average of 1.88 ± 1.03 revisions per patient. The average normalized presurgery, postsurgery, and final aggregate numeric patient outcome scores were 0.37 ± 0.13, 0.63 ± 0.18, and 0.61 ± 0.19, respectively, with a score of 0 and 1 representing the worst and best possible score.Degenerative spine surgery in patients with PD is challenging, with complications and revisions occurring in up to a third of treated patients. Surgery should be offered when other treatment options have proved ineffective and is typically reserved for patients with myelopathy or significant disability. Successful outcomes depend on strong interdisciplinary support to control the movement disorder before and after surgery.

Middle cranial fossa surgery commonly is approached either performing a subtemporal or a pterional craniotomy. To maximize a basitemporal region exposure, an adjunctive bone drilling could be required. In these cases, a watertight dura and temporalis muscle closure are mandatory.To describe a modified temporalis muscle dissection in middle cranial fossa surgery to increase basitemporal region exposure while assuring a safe and effective closure thus avoiding cerebrospinal fluid (CSF) leakage.A total of 8 patients have been enrolled. Five pterional and 3 subtemporal approaches were performed. In all cases, the novel subfascial muscle dissection and temporalis muscle splitting technique named "the double S technique," was performed to cut up the temporal muscle.In all cases, a subgaleal drainage was used and removed within 48 hours. No cases of postoperative CSF leak or hematoma collection were reported.The double S technique is a safe and effective alternative to enhance the basitemporal region exposure while avoiding the potential, common risk of CSF leak.

Posterior epidural intervertebral disc migration and sequestration (PEIMS) is a rare and debilitating complication of degenerative disc disease. Radiological differential diagnosis is often challenging, complicating the accurate planning of appropriate treatment strategies. We systematically reviewed the literature on PEIMS, focusing on clinical-radiological features and available treatments. PubMed, Scopus, Web of Science, and Cochrane were searched to include studies reporting clinical data of patients with PEIMS. Clinical characteristics, treatment strategies, and functional outcomes were analyzed. We included 82 studies comprising 157 patients. Median age was 54 years (range, 19-91). PEIMSs occurred spontaneously (49.7%) or acutely in patients with underlying progressive degenerative disc disease (50.3%). The most common symptoms were lower-back pain (77.1%) and radiculopathy (66.2%), mainly involving the L5 nerve root (43.8%). PEIMSs were mostly detected at MRI (93%) and/or CT (7%), frequently located in the lumbar spine (81.5%). Median maximum PEIMS diameter was 2.4 cm (range, 1.2-5.0). Surgical debulking was completed in 150 patients (95.5%), sometimes coupled with decompressive laminectomy (65%) or hemilaminectomy (19.1%). Median follow-up time was 3 months (range, 0.5-36.0). Post-treatment symptomatic improvement was reported in 153 patients (97.5%), with total recovery in 118 (75.2%). All 7 patients (4.5%) who received conservative non-surgical management had total clinical recovery at ≤ 3 months follow-ups. PEIMS is a challenging entity that may severely quality-of-life in patients with degenerative disc disease. Surgical removal represents the gold standard to improve patient's functional status. Spine fusion and conservative strategies proved to be effective in some cases.

Gamma Knife radiosurgery (GKRS) is feasible for pituitary adenomas, but post-surgery GKRS may cause severe hormone deficits. We reviewed the literature on primary GKRS for pituitary adenoma focusing on radiation-induced hormone deficiencies.PubMed, Web-of-Science, Scopus, and Cochrane were searched upon the PRISMA guidelines to include studies describing primary GKRS for pituitary adenomas. Pooled-rates of GKRS-induced hormone deficiencies and clinical-radiological responses were analyzed with a random-effect model meta-analysis.We included 24 studies comprising 1381 patients. Prolactinomas were the most common (34.2%), and 289 patients had non-functioning adenomas (20.9%). Median tumor volume was 1.6cmPrimary GKRS for pituitary adenoma may correlate with lower rates of radiation-induced hypopituitarism (11.4%) than post-surgery GKRS (18-32%). Minimal doses to normal pituitary structures and long-term endocrine follow-up are of primary importance.

OBJECTIVE Spine hepatocellular carcinoma (HCC) metastases severely worsen quality of life and prognosis, with the role of radiotherapy being controversial. The authors systematically reviewed the literature on radiotherapy for spine metastatic HCCs. METHODS The PubMed, Scopus, Web of Science, and Cochrane databases were searched according to the PRISMA guidelines to include studies of radiotherapy for spine metastatic HCCs. Outcomes, complications, and local control were analyzed with indirect random-effect meta-analyses. RESULTS The authors included 12 studies comprising 713 patients. The median time interval from diagnosis of HCC to spine metastases was 12 months (range 0–105 months). Most lesions were thoracic (35.9%) or lumbar (24.7%). Radiotherapy was delivered with conventional external-beam (67.3%) or stereotactic (31.7%) techniques. The median dose was 30.3 Gy (range 12.5–52 Gy) in a median of 5 fractions (range 1–20 fractions). The median biologically effective dose was 44.8 Gy10 (range 14.4–112.5 Gy10). Actuarial rates of postradiotherapy pain relief and radiological response were 87% (95% CI 84%–90%) and 70% (95% CI 65%–75%), respectively. Radiation-related adverse events and vertebral fractures had actuarial rates of 8% (95% CI 5%–11%) and 16% (95% CI 10%–23%), respectively, with fracture rates significantly higher after stereotactic radiotherapy (p = 0.033). Fifty-eight patients (27.6%) had local recurrences after a median of 6.8 months (range 0.1–59 months), with pooled local control rates of 61.6% at 6 months and 40.8% at 12 months, and there were no significant differences based on radiotherapy type (p = 0.068). The median survival was 6 months (range 0.1–62 months), with pooled rates of 52.5% at 6 months and 23.4% at 12 months. CONCLUSIONS Radiotherapy in spine metastatic HCCs shows favorable rates of pain relief, radiological responses, and local control. Rates of postradiotherapy vertebral fractures are higher after high-dose stereotactic radiotherapy.

Ischemic stroke has been estimated to occur in up to 26% of patients with blunt cerebrovascular injury (BCVI). Antithrombotic therapy (AT) may be used for stroke prevention, but the role of endovascular treatment (ET) remains unclear. We systematically reviewed the literature on AT and ET for the treatment of patients with BCVIs.PubMed, EMBASE, Web of Science, and Cochrane were searched upon the PRISMA guidelines to include studies reporting the use of ET in BCVI patients. Post-ET neurologic outcomes, radiographic responses, and complication rates were assessed. A fixed-effect model meta-analysis was performed to compare treatment-related post-BCVI ischemic stroke rates between AT and ET protocols.We included 16 studies comprising 352 patients undergoing ET for BCVI. Mean post-ET rates of good neurologic outcomes and radiologic responses were 86.9% (range, 63.6-100%) and 94.0% (range 57.1-100%), respectively. Mean post-ET complication rate was 5.2% (range, 0-66.7%). Seven studies compared the roles of AT (delivered in 805 patients) and ET (performed in 235 patients) for preventing the onset of post-BCVI ischemic strokes. No significant difference in rates of post-BCVI ischemic stroke was found between patients receiving AT vs patients undergoing ET (OR 0.71, 95% CI: 0.35-1.42, p = 0.402).AT and ET may be comparable in preventing the occurrence of ischemic stroke following BCVIs. AT may be preferred as the less-invasive first-line therapy, but ET showed favorable rates of post-treatment clinical and radiologic outcomes, coupled with low rates of treatment-related complications.

Background: While several publications have focused on the intuitive role of augmented reality (AR) and virtual reality (VR) in neurosurgical planning, the aim of this review was to explore other avenues, where these technologies have significant utility and applicability. Methods: This review was conducted by searching PubMed, PubMed Central, Google Scholar, the Scopus database, the Web of Science Core Collection database, and the SciELO citation index, from 1989–2021. An example of a search strategy used in PubMed Central is: “Virtual reality” [All Fields] AND (“neurosurgical procedures” [MeSH Terms] OR (“neurosurgical” [All Fields] AND “procedures” [All Fields]) OR “neurosurgical procedures” [All Fields] OR “neurosurgery” [All Fields] OR “neurosurgery” [MeSH Terms]). Using this search strategy, we identified 487 (PubMed), 1097 (PubMed Central), and 275 citations (Web of Science Core Collection database). Results: Articles were found and reviewed showing numerous applications of VR/AR in neurosurgery. These applications included their utility as a supplement and augment for neuronavigation in the fields of diagnosis for complex vascular interventions, spine deformity correction, resident training, procedural practice, pain management, and rehabilitation of neurosurgical patients. These technologies have also shown promise in other area of neurosurgery, such as consent taking, training of ancillary personnel, and improving patient comfort during procedures, as well as a tool for training neurosurgeons in other advancements in the field, such as robotic neurosurgery. Conclusions: We present the first review of the immense possibilities of VR in neurosurgery, beyond merely planning for surgical procedures. The importance of VR and AR, especially in “social distancing” in neurosurgery training, for economically disadvantaged sections, for prevention of medicolegal claims and in pain management and rehabilitation, is promising and warrants further research.

Background: Spine aneurysmal bone cysts (ABCs) rarely occur in adults. Primary and secondary lesions may show some differences and require appropriate treatments. Objective: To systematically review the literature on adult spine ABCs. Methods: PubMed, EMBASE, Scopus, and Web-of-Science were searched. Clinical-radiological features, treatments, and outcomes were analyzed and compared between primary vs secondary adult spine ABCs. Results: We included 80 studies comprising 220 patients. Primary spine ABCs were more frequent (76.4%). Main symptoms were lower-back-pain (42.8%) and motor deficits (31.2%). Tumors were mostly thoracic (31.4%) or cervical (26.8%), showing lytic (70.4%) and/or cystic (52.3%) appearances. Surgical resection (79.1%) was preferred over biopsy (20.9%). Most primary ABCs underwent curettage with bone grafting (62.1%) and laminectomy (39.1%) (P < 0.001), while most secondary ABCs underwent corpectomy (51%) and spine fixation (93.9%) (P < 0.001). Radiotherapy was delivered in 58 patients (26.4%), and embolization in 37 (16.8%). Symptomatic improvement was reported in 91.8% cases, with no differences based on etiology nor extent-of-resection. Median follow-up was 28.5 months, significantly superior in secondary ABCs. Secondary ABCs had significantly higher rates of tumor recurrence (19.2%; P = 0.011) and death (5.8%; P = 0.002). Conclusion: Surgical resection, radiotherapy, and embolization are effective in managing adult spine ABCs. Secondary tumors have worse prognoses requiring more aggressive treatments.

Leptomeningeal metastases (LMs) of the spine have complex management. We reviewed the literature on spine LMs.PubMed, EMBASE, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA guidelines to include studies of spine LMs.We included 46 studies comprising 72 patients. The most frequent primary tumors were lung (19.4%) and breast cancers (19.4%). Median time from primary tumors was 12 months (range=0-252 months). Cauda equina syndrome occurred in 34 patients (48.6%). Nodular spine LMs (63.6%) were more frequent. Concurrent intracranial LMs were present in 27 cases (50.9%). Cerebrospinal fluid cytology was positive in 31 cases (63.6%). Cases were managed using palliative steroids (73.6%) with locoregional radiotherapy (55.6%) chemotherapy (47.2%), or decompressive laminectomy (8.3%). Post-treatment symptom improvement (32%) and favorable radiological response (28.3%) were not different based on treatment (p=0.966; p=0.727). Median overall-survival was 3 months (range=0.3-60 months), not significantly different between radiotherapy and chemotherapy (p=0.217).Spine LMs have poor prognoses. Radiotherapy, chemotherapy, and surgery are only palliative, as described for intracranial LMs.

Traumatic brain injury (TBI) is a multifaceted condition that causes mortality and disability worldwide. Limited data are available on the factors associated with the decision for the withdrawal of life-sustaining treatment (WLST) for patients with TBI. In the present study, we aimed to determine the risk factors and attitudes affecting neurosurgeons when deciding on WLST for patients with TBI using a multicenter survey.An online questionnaire was applied worldwide and shared using social media platforms and electronic mail to ∼5000 neurosurgeons. The social media group "Neurosurgery Cocktail" was used to post a link to the questionnaire. In addition, randomly chosen neurosurgery clinics around the world were sent the survey via electronic mail.Of the participants, 17.22% had decided on WLST after TBI for26 patients. Neurosurgeons with more WLST decisions were older, had had more clinical experience and intensive care unit (ICU) training, and were better prepared to involve the family members of TBI patients in their decision-making compared with those with fewer WLST decisions. The respondents stated that the patient's family, ICU consultants, and themselves played the most influential role in the WLST decisions, with the hospital administration, social workers, spiritual caregivers, and nurses having lesser roles. The current and presenting Glasgow coma scale scores, pupillary response, advanced patient age, candidates for a vegetative state, and impaired neurological function were significant factors associated with the WLST decision.To the best of our knowledge, the present study is the first to evaluate neurosurgeons concerning their opinions and behaviors regarding WLST decisions after TBI. Increased patient age, Glasgow coma scale score, pupillary response, the presence of comorbidities, candidacy for a vegetative state, and impaired neurological function were the main factors contributing to the decision for WLST. We also found that the family, ICU consultants, and the attending neurosurgeon had the most effective roles in the decisions regarding WLST.

Primary spine paragangliomas are rare tumors. Surgical resection plays a role, but aggressive lesions are challenging. We reviewed the literature on primary spine paragangliomas.PubMed, Scopus, Web of Science, and Cochrane were searched following the PRISMA guidelines to include studies on primary spine paragangliomas. Clinical-radiologic features, treatments, and outcomes were analyzed and compared between cauda equina versus non-cauda equina tumors.We included 143 studies comprising 334 patients. Median age was 46 years (range, 6-85 years). The most frequent symptoms were lower back (64.1%) and radicular (53.9%) pain, and sympathetic in 18 patients (5.4%). Cauda equina paragangliomas (84.1%) had frequently lumbar (49.1%) or lumbosacral (29%) locations. Non-cauda equina tumors were mostly in the thoracic (11.4%), thoracolumbar (5.1%), and cervical (3.6%) spine. Median tumor diameter was 2.5 cm (range, 0.5-13.0 cm). Surgical resection (98.5%) was preferred over biopsy (1.5%). Decompressive laminectomy (53%) and spine fusion (6.9%) were also performed. Adjuvant radiotherapy was delivered in 39 patients (11.7%) with aggressive tumors. Posttreatment symptomatic improvement was described in 86.2% cases. Median follow-up was 19.5 months (range, 0.1-468.0 months), and 23 patients (3.9%) had tumor recurrences. No significant differences were found between cauda equina versus non-cauda equina tumors.Surgical resection is effective and safe in treating primary spine paragangliomas; however, adjuvant treatments may be needed for aggressive lesions.

Pineal region metastases are rare but often cause severe neurologic deficits. Surgical resection and chemoradiotherapy can provide therapeutic benefit. We investigated the literature to analyze clinical characteristics, management strategies, and survival of adult patients with pineal region metastases.PubMed, Embase, Scopus, and Cochrane were searched following the PRISMA guidelines, including studies reporting clinical outcomes of patients with pineal region metastases. Clinical presentation, management, and survival were reviewed.We included 31 studies comprising 47 patients. Lung cancer (29.8%) and carcinomas of unknown origin (14.9%) were the most frequent primary tumors. In 48.9% of patients, symptomatic pineal metastases preceded primary tumor diagnosis. Headache (67.4%) and confusion (46.5%) were the most common symptoms. Parinaud syndrome (46.5%) and hydrocephalus (87.2%) were noted. Biopsy (65.9%) was preferred over resection (34.1%), and shunting strategies used were endoscopic third ventriculostomy (43.9%) and ventriculoperitoneal (26.8%). Eleven patients (32.3%) received adjuvant chemotherapy and 32 (68%) received radiotherapy. Posttreatment improvement in symptoms (56.6%) and hydrocephalus (80.5%) were noted. In patients who received adjuvant chemotherapy/radiotherapy, significant improvement in posttreatment performance status occurred with both biopsy (P0.001) and resection (P = 0.007). No survival differences were reported between surgery and biopsy (P = 0.912) or between complete and partial resection (P = 0.220). Overall survival was neither influenced by surgical approach (P = 0.157) nor by shunting strategy (P = 0.822). Mean follow-up was 8 months and median overall survival 3 months. Only 2 cases (4.8%) of pineal metastasis showed recurrence.Pineal region metastases carry significant morbidity. Biopsy or surgical resection, combined with adjuvant chemotherapy/radiotherapy and/or shunting, may significantly improve performance status.