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BACKGROUND Recurrent intracranial tumors frequently require re-resection. Dural adhesions to the cortex increase the morbidity and duration of these revision craniotomies. OBJECTIVE To describe the use of commercially available sterile gelatin film to prevent meningocerebral adhesions and decrease the rate of surgically induced ischemia from revision craniotomy. METHODS This retrospective cohort study examined patients with recurrent glioma, meningioma, and metastasis who underwent re-resection at least 30 d following their initial tumor resection. Cortical surface tissue ischemia after re-resection on diffusion-weighted magnetic resonance imaging was compared for patients with (gelatin film group) and without (nongelatin film group) a history of gelatin film placement at the conclusion of their initial tumor resection. RESULTS A total of 84 patients in the gelatin film group were compared to 86 patients in the nongelatin film group. Patient age, sex, tumor pathology, tumor volume, tumor eloquence, laterality of surgical approach, history of radiotherapy, and time interval between resections did not differ between groups. Radiographic evidence of cortical ischemia following reoperation was less prevalent in the gelatin film group (13.1% vs 32.6%; P

BACKGROUND Accurate stereotactic biopsies of brain tumors are imperative for diagnosis and tailoring of the therapy. Repetitive needle insertions enhance risks of brain lesioning, hemorrhage, and complications due to prolonged procedure. OBJECTIVE To investigate clinical benefits of a combined 5-aminolaevulinic acid (5-ALA) fluorescence and laser Doppler flowmetry system for the detection of malignant brain tumor and blood vessels in stereotactic biopsies. METHODS Planning of targets and trajectories was followed by optical measurements in 20 patients, using the Leksell Stereotactic System and a manual insertion device. Fluorescence spectra, microvascular blood flow, and tissue grayness were recorded each millimeter along the paths. Biopsies were taken at preplanned positions. The diagnoses were compared with the fluorescence signals. The recordings were plotted against measurement positions and compared. Sites indicating a risk of hemorrhage were counted as well as the time for the procedures. RESULTS Signals were recorded along 28 trajectories, and 78 biopsies were collected. The final diagnosis showed 17 glioblastomas, 2 lymphomas, and 1 astrocytoma grade III. Fluorescence was seen along 23 of the paths with 4 having the peak of 5-ALA fluorescence 3 mm or more from the precalculated target. There was increased microcirculation in 40 of 905 measured positions. The measurement time for each trajectory was 5 to 10 min. CONCLUSION The probe provided direct feedback of increased blood flow along the trajectory and of malignant tissue in the vicinity of the target. The method can increase the precision and the safety of the biopsy procedure and reduce time. Funding: LiU Cancer Strategic Research Grant; Swedish Childhood Cancer FoundationEuropean Commission [MT 20130043]; ALF Grants Region Ostergotland; Swedish Foundation for Strategic ResearchSwedish Foundation for Strategic Research [RMX18-0056]

Orbital metastatic lesions are rare entities1-3 best treated with radical surgical resection with preservation/improvement of neurological and visual function.1-9 Renal cell metastases, in particular, respond less favorably to radiation.9 To our knowledge, an operative video of microsurgical resection of a renal cell carcinoma metastasis to the superior orbital fissure and orbit has not been reported. A patient presented with worsening right eye vision as demonstrated on preoperative visual field testing and found to have a 3 × 1 × 1 cm lesion in the orbit and superior orbital fissure. The patient was placed supine and stealth neuronavigation was used to aid in tumor localization and extension. A cranio-orbital craniotomy and pretemporal exposure2,10,11 were performed to allow extradural dissection of the dura propria off the lateral wall of the cavernous sinus. Right-sided extradural cranial nerves II, III, IV, V1, and V2 were identified, and a high-speed diamond drill was used to perform extradural anterior clinoidectomy and optic nerve decompression. Microsurgical resection of the intraorbital tumor components was performed by the senior author (KIA) to delineate the plane between tumor and periorbita. An oval-shaped dural opening was made to resect the dura involved by tumor, confirmed on histological analysis, followed by closure via dural allograft. The patient's right-sided visual field improved markedly after surgery. Metastatic renal cell carcinoma of the orbit should be resected while preserving and improving preoperative neurological and visual function. The orbitocranial pretemporal approach offers wide visualization to achieve surgical resection. The patient provided written consent and permission to publish her image.

Dumbbell schwannoma of the cervical spine is a known entity,1-5 and should be radically resected with the preservation or improvement of neurological function. However, to our knowledge, an operative video of a C1-C2 cervical dumbbell schwannoma with ventral extension and dorsal spinal cord compression has not been reported previously. This tumor resection video performed by the senior author (KIA) includes details of dural opening, and techniques for microsurgical resection and for postoperative closure to avoid cerebrospinal fluid (CSF) leak and pseudomeningocele formation. Fat grafting was performed through a small paraumbilical incision. The patient was prone in MAYFIELD 3-point pin fixation (Integra LifeSciences, Plainsboro Township, New Jersey). Intraoperative neurophysiological electrodes were placed for somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring. Stealth neuronavigation was used to aid in tumor localization. A small suboccipital craniectomy and C1 laminectomy were performed before opening the dura. Using a microsurgical technique, the dura was opened in the form of the letter “Y.” The right-sided dentate ligament was cut to aid in the mobilization of the tumor away from the spinal cord. After dividing the tumor at the dumbbell isthmus, the ventral tumor component was removed, with attention paid to the division of a perforator coming from the vertebral artery. Intraforaminal tumor debulking was performed with a cavitron ultrasonic surgical aspirator (CUSA) and resected. High cervical dumbbell schwannoma should be radically resected while preserving and improving preoperative neurological function. Avoidance of CSF leak and formation of pseudomeningocele should be planned at the beginning, utilizing fascia and fat graft to avoid this feared complication. The patient provided written consent and permission to publish her image.

In this video, we demonstrate microsurgical resection of IV ventricle subependymoma. To the best of our knowledge, this is the first video case report of a microsurgical resection of subependymoma of the IV ventricle in the peer-reviewed English literature. Subependymomas are benign central nervous system tumors, typically arising in ventricular spaces, mostly in the IV and lateral ventricles.1-3 They are isointense on T1 and hyperintense on T2-weighted magnetic resonance imaging (MRI) with minimal or no enhancement.4 Microsurgery remains the mainstay treatment. Complete tumor resection is possible and curative with excellent prognosis.1,5-7 Although the clinical course appears benign, the inability to diagnose them radiographically with certainty and the possibility of an alternative malignant lesion support a low threshold for early and safe resection.8 A 39-yr-old man presented with severe headache and balance problems. Pre- and postcontrast neuroaxis MRI revealed a centrally located IV ventricle lesion without hydrocephalus. The aim of the surgery was complete tumor resection. Surgery was performed in the prone position by the senior author (KIA) with intraoperative neurophysiology monitoring. A small suboccipital craniotomy and C1 posterior arch removal was done. After opening the dura and arachnoid membrane, the tumor was identified and meticulously dissected from the adjacent posterior inferior cerebellar artery and the floor of the fourth ventricle and from brain stem white matter at the tumor-neural tissue interface to avoid brainstem interference. Histological analysis revealed subependymoma (World Health Organization Grade I). Postoperative pre- and postcontrast MRI revealed complete resection. Headache and balance problems completely resolved; the patient was neurologically intact. The patient provided written consent and permission to publish his image.