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MGMT promoter methylation is related to the increased sensitivity of tumour tissue to chemotherapy with temozolomide (TMZ) and thus to improved patient survival. However, it is unclear how the extent of MGMT promoter methylation affects outcomes. In our study, a single-centre retrospective study, we explore the impact of MGMT promoter methylation in patients with glioblastoma who were operated upon with 5-ALA. Demographic, clinical and histology data, and survival rates were assessed. A total of 69 patients formed the study group (mean age 53.75 ± 15.51 years old). Positive 5-ALA fluorescence was noted in 79.41%. A higher percentage of MGMT promoter methylation was related to lower preoperative tumour volume (p = 0.003), a lower likelihood of 5-ALA positive fluorescence (p = 0.041) and a larger extent of resection EoR (p = 0.041). A higher MGMT promoter methylation rate was also related to improved progression-free survival (PFS) and overall survival (OS) (p = 0.008 and p = 0.006, respectively), even when adjusted for the extent of resection (p = 0.034 and p = 0.042, respectively). A higher number of adjuvant chemotherapy cycles was also related to longer PFS and OS (p = 0.049 and p = 0.030, respectively). Therefore, this study suggests MGMT promoter methylation should be considered as a continuous variable. It is a prognostic factor that goes beyond sensitivity to chemotherapy treatment, as a higher percentage of methylation is related not only to increased EoR and increased PFS and OS, but also to lower tumour volume at presentation and a lower likelihood of 5-ALA fluorescence intraoperatively.

Safe Trajectory planning for navigation guided biopsy (nBx) of motor eloquent tumours (METs) is important to minimise neurological morbidity. Preliminary clinical data suggest that visualisation of the corticospinal tract (CST) and its relation to the tumour may aid in planning a safe trajectory. In this article we assess the impact of tractography in nBx planning in a simulation-based exercise. This single centre cross-sectional study was performed in March 2021 including 10 patients with METs divided into 2 groups: (1) tractography enhanced group (T-nBx; n = 5; CST merged with volumetric MRI); (2) anatomy-based group (A-nBx; n = 5; volumetric MRI only). A biopsy target was chosen on each tumour. Volunteer neurosurgical trainees had to plan a suitable biopsy trajectory on a Stealth S8® workstation for all patients in a single session. A trajectory safety index (TSI) was devised for each trajectory. Data collection and analysis included a comparison of trajectory planning time, trajectory/lobe changes and TSI. A total of 190 trajectories were analysed based on participation from 19 trainees. Mean trajectory planning time for the entire cohort was 225.1 ± 21.97 s. T-nBx required shorter time for planning (p = 0.01). Mean trajectory changes and lobe changes made per biopsy were 3.28 ± 0.29 and 0.45 ± 0.08, respectively. T-nBx required fewer trajectory/lobe changes (p = 0.01). TSI was better in the presence of tractography than A-nBx (p = 0.04). Neurosurgical experience of trainees had no significant impact on the measured parameters despite adjusted analysis. Irrespective of the level of neurosurgical training, surgical planning of navigation guided biopsy for METs may be achieved in less time with a safer trajectory if tractography imaging is available.

Objective Chordoma is a rare neoplasm of the neuraxis derived from remnants of the primitive notochord. The importance of wide margins and use of adjuvant therapy in spinal chordomas are still contentious points in the management of spinal chordomas. We conducted a systematic review of the surgical management of spinal chordomas alongside our 10-year institutional experience. Methods A systematic search of the literature was performed in November 2020 using Embase and MEDLINE for articles regarding the surgical management of chordomas arising from the mobile spine and sacrum. We also searched for all adult patients who were surgically managed for spinal chordomas at our institute between 2010 and 2020. In both the systematic review and our institutional case series, data on adequacy of resection, use of adjuvant therapy, complications, recurrence (local or metastatic), and survival outcomes were collected. Results We identified and analyzed 42 articles, yielding 1531 patients, from which the overall gross total or wide resection rate was 54.9%. Among the 8 cases in our institutional experience (4 sacral, 3 cervical, and 1 lumbar), we achieved gross total resection in 50% of initial operations. The recurrence rate was 25% in our gross total resection group and 50% where initial resection was subtotal. Of patients, 75% had no evidence of recurrence at most recent follow-up. Conclusions Albeit difficult at times because of the proximity to neurovascular tissue, achieving a wide resection followed by adjuvant therapy for spinal chordomas is of great importance. Multidisciplinary discussion is valuable to ensure the best outcome for the patient.

This study aims to review therapeutic strategies in the management of craniospinal tumors in pregnant patients and the factors that may influence the management along with their influence on maternal and fetal outcomes.A retrospective single-center cohort study was performed at a tertiary neurosurgical referral center. Pregnant patients referred to the neuro-oncology multidisciplinary meeting (MDM) with craniospinal tumor were included. Ten-year patient data were collected from hospital records and neuro-oncology MDM outcomes. A systematic review was performed of the available literature as per PRISMA guidelines.Twenty-five patients were identified, with a mean age of 31 years. Of these patients, 88% (n = 22) had cranial lesions and 12% (n = 3) had spinal lesions. Most of the patients had World Health Organization grade I/II tumors. Of the patients, 44% underwent surgery when pregnant, whereas in 40%, this was deferred until after the due date. Of patients, 16% did not require surgical intervention and were followed up with serial imaging in the MDM. The left lateral/park bench position was the preferred position for the spinal and posterior fossa lesions. Systematic review and retrospective data led to proposal of treatment algorithms addressing the therapeutic strategy for management of craniospinal tumors during pregnancy. Factors that may influence maternal and fetal outcomes during management of these tumors were identified, including aggressiveness of the tumor and stage of pregnancy.Craniospinal tumors presenting in pregnancy are challenging. The surgical management needs to be tailored individually and as part of a multidisciplinary team approach. Factors influencing maternal and fetal outcomes are to be considered during management and patient counseling.

Introduction: Penfield’s motor homunculus describes a caricaturised yet useful representation of the map of various body parts on the pre-central cortex. We propose a supplemental map of the clinically represented areas of human body in pre-central cortex and a novel subcortical corticospinal tract map that are accurate and essential for safe surgery in patients with eloquent brain lesions. Materials and methods: A single-institution retrospective cohort study of patients who underwent craniotomy for motor eloquent lesions with intraoperative motor neuromonitoring (cortical and subcortical) between 2015 and 2020 was performed. All positive cortical and subcortical stimulation points were taken into account and cartographic maps were produced to demonstrate cortical and subcortical areas of motor representation and their configuration. A literature review in PubMed was performed. Results: 180 patients (58.4% male, 41.6% female) were included in the study with 81.6% asleep and 18.4% awake craniotomies for motor eloquent lesions (gliomas 80.7%, metastases 13.8%) with intraoperative cortical and subcortical motor mapping. Based on the data, we propose a supplemental clinical cortical and a novel subcortical motor map to the original Penfield’s motor homunculus, including demonstration of localisation of intercostal muscles both in the cortex and subcortex which has not been previously described. Conclusion: The supplementary clinical cortical and novel subcortical motor maps of the homunculus presented here have been derived from a large cohort of patients undergoing direct cortical and subcortical brain mapping. The information will have direct relevance for improving the safety and outcome of patients undergoing resection of motor eloquent brain lesions.

Background: The role played by the non-dominant parietal lobe in motor cognition, attention and spatial awareness networks has potentiated the use of awake surgery. When this is not feasible, asleep monitoring and mapping techniques should be used to achieve an onco-functional balance. Objective: This study aims to assess the feasibility of a dual-strip method to obtain direct cortical stimulation for continuous real-time cortical monitoring and subcortical mapping of motor and visual pathways simultaneously in parietal lobe tumour surgery. Methods: Single-centre prospective study between May’19-November’20 of patients with intrinsic non-dominant parietal-lobe tumours. Two subdural strips were used to simultaneously map and monitor motor and visual pathways. Results: Fifteen patients were included. With regards to motor function, a large proportion of patients had abnormal interhemispheric resting motor threshold ratio (iRMTr) (71.4%), abnormal Cortical Excitability Score (CES) (85.7%), close distance to the corticospinal tract – Lesion-To-Tract Distance (LTD) – 4.2mm, Cavity-To-Tract Distance (CTD) – 7mm and intraoperative subcortical distance - 6.4mm. Concerning visual function, the LTD and CTD for optic radiations (OR) were 0.5mm and 3.4mm, respectively; the mean intensity for positive subcortical stimulation of OR was 12mA±2.3mA and 5/6 patients with deterioration of VEPs>50% had persistent hemianopia and transgression of ORs. 12 patients remained stable, one patient had a de-novo transitory hemiparesis, and two showed improvements in motor symptoms. A higher iRMTr for lower limbs was related with a worse motor outcome (p=0.013) and a longer CTD to OR was directly related with a better visual outcome (p=0.041). At 2 weeks after hospital discharge, all patients were ambulatory at home and all proceeded to have oncological treatment. Conclusion: We propose motor and visual function boundaries for asleep surgery of intrinsic non-dominant parietal tumours. Pre-operative abnormal cortical excitability of the motor cortex, deterioration of the VEP recordings and CTD

Background: Colloid cysts, although benign, may occasionally cause obstructive hydrocephalus and sudden death. Reliable prognostic factors for symptomatic progression have been sought, with heterogenous results. Methods: We conducted a retrospective review of all cases of colloid cysts of the third ventricle managed at our center between 2009 and 2019. Clinical and neuroimaging characteristics were analyzed using logistic regression in relation to symptomatic status and hydrocephalus. The cutoff values for outcome prediction were calculated using the receiver operating characteristic curve analysis. Results: There were 82 patients with colloid cysts, of whom 60 were asymptomatic and 22 symptomatic. None of the asymptomatic patients experienced acute neurologic decline or hydrocephalus during follow-up, whereas half (n = 11) of the symptomatic patients presented with hydrocephalus, 8 of whom had acute hydrocephalus. We found 3 putative candidate risk factors for symptomatic colloid cysts: T1-weighted magnetic resonance imaging hyperintense/mixed signal appearance (P = 0.004), location in risk zone I (P = 0.007), and a volume >236.49 mm 3 (P = 0.007). Cyst diameter and volume/foramen of Monro diameter ratios had a decreasing trend over time among asymptomatic patients, providing new insights into the natural history of the disease. Conclusions: Only a few asymptomatic colloid cysts showed progression requiring surgery, with no acute deterioration or fatal events, whereas the rest remained stable over time, thus supporting a more conservative approach for this group of patients. Higher risk for developing symptomatic colloid cyst was defined by a risk score that included T1-weighted magnetic resonance imaging appearance, risk zone, and colloid cyst volume, aiding the detection of patients at risk of clinical deterioration.

Introduction Isolated acute bilateral foot drop due to degenerative spine disease is an extremely rare neurosurgical presentation, whilst the literature is rich with accounts of chronic bilateral foot drop occurring as a sequela of systemic illnesses. We present, to our knowledge, the largest case series of acute bilateral foot drop, with trauma and relevant systemic illness excluded. Methods Data from three different centres had been collected at the time of historic treatment, and records were subsequently reviewed retrospectively, documenting the clinical presentation, radiological level of compression, timing of surgery, and degree of neurological recovery. Results Seven patients are presented. The mean age at presentation was 52.1 years (range 41–66). All patients but one were male. All had a painful radiculopathic presentation. Relevant discopathy was observed from L2/3 to L5/S1, the commonest level being L3/4. Five were treated within 24 h of presentation, and two within 48 h. Three had concomitant cauda equina syndrome; of these, the first two made a full motor recovery, one by 6 weeks follow-up and the second on the same-day post-op evaluation. Overall, five out of seven cases had full resolution of their ankle dorsiflexion pareses. One patient with 1/5 power has not improved. Another with 1/5 weakness improved to normal on the one side and to 3/5 on the other. Conclusion When bilateral foot drop occurs acutely, we encourage the consideration of degenerative spinal disease. Relevant discopathy was observed from L2/3 to L5/S1; aberrant innervation may be at play. Cauda equina syndrome is not necessarily associated with acute bilateral foot drop. The prognosis seems to be pretty good with respect to recovery of the foot drop, especially if partial at presentation and if treated within 48 h.

Background/aim The outlook for patients with high grade glioma (HGG) remains dismal. Hence, attention has focused on numerous innovative treatments. Our group has proposed a strategy on the use of a combination of polyphenols, as anti-invasive agents for the management of these neoplasms. Materials and methods The aim of this study was to evaluate the in vitro effects of citrus flavonoids (tangeretin, nobiletin, naringin and limonin) and berry extracts (chokeberry, elderberry and bilberry) on selected mediators of invasion in 2 HGG cell cultures. Results The IC50 values could only be determined for tangeretin and chokeberry extract. The rest were non-functional in this context. Immunocytochemistry and flow cytometry results showed that chokeberry extract was most effective in down-regulating the expression of CD44. Similarly, RT-PCR data supported its ability to reduce gene expression of MMP-14 and EGFR. 2D invasion assays confirmed that inhibition is greater with chokeberry extract. Conclusion Both polyphenols have anti-invasive potential but chokeberry extract is a stronger agent for glioma management.

Introduction and objectivesThe novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had drastic effects on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-economically diverse population.MethodsA prospective single-centre cohort study including all patients referred to the acute neurosurgical service or the subspecialty multidisciplinary teams (MDT) as well as all emergency and elective admissions during COVID-19 (18th March 2020–15th May 2020) compared to pre-COVID-19 (18th of January 2020–17th March 2020). Data on demographics, diagnosis, operation, and treatment recommendation/outcome were collected and analysed.ResultsOverall, there was a reduction in neurosurgical emergency referrals by 33.6% and operations by 55.6% during the course of COVID-19. There was a significant increase in the proportion of emergency operations performed during COVID-19 (75.2% of total,n=155) when compared to pre-COVID-19 (n= 198, 43.7% of total,p< 0.00001). In contrast to other published series, the 30-day perioperative mortality remained low (2.0%) with the majority of post-operative COVID-19-infected patients (n= 13) having underlying medical co-morbidities and/or suffering from post-operative complications.ConclusionThe capacity to safely treat patients requiring urgent or emergency neurosurgical care was maintained at all times. Strategies adopted to enable this included proactively approaching the referrers to maintain lines of communications, incorporating modern technology to run clinics and MDTs, restructuring patient pathways/facilities, and initiating the delivery of NHS care within private sector hospitals. Through this multi-modal approach we were able to minimize service disruptions, the complications, and mortality.

Background Paragangliomas are uncommon neuroendocrine tumors, rarely occurring in the lumbar spine. Primary lumbar paragangliomas are prominently vascularized, can present variably, and pose both diagnostic and surgical challenges. We report on a large case series with long-term follow-up and intraoperative footage to characterize the natural history, diagnostic approach, and operative approach to this rare surgical disease. Methods This is a single-center, retrospective cohort study including all patients with histologically confirmed primary lumbar paraganglioma treated at our tertiary neurosurgical center between 1997 and 2018. Clinical, radiologic, surgical, and histologic data were collected from medical records. Results There were 13 cases of primary lumbar paraganglioma (8 men [61.5%], 5 women [38.5%]; mean age, 51.3 years; range, 33.2–68.9 years). Symptom duration correlated with tumor size (Spearman r = 0.735, P = 0.01). The main presenting symptoms were lower back pain and radiculopathy, often long-standing with recent deterioration. Seven patients (53.8%) were admitted as emergency cases, including 3 with cauda equina syndrome. Preoperative differential diagnoses included nerve sheath tumor, ependymoma, meningioma, and disk herniation. The mean Ki-67 mitotic index was 5.7% (range, 1%–10%). Surgical resection improved pain in 8 of 13 patients (61.5%) and weakness improved in 5 of 5 patients (100%). Conclusions Primary lumbar paragangliomas are rare neoplasms of the cauda equina that typically progress slowly but may also present acutely. They are often related to the filum terminale, which should be resected prior to other attachments intraoperatively to prevent displacement of the tumor out of view. Total resection can be curative, and long-term follow-up in this series found no recurrence.

BACKGROUND/AIM: The tetrazolium-based MTT cytotoxicity assay is well established for screening putative anti-cancer agents. However, it has limitations including lack of reproducibility with glioma cells treated with polyphenols. The aim of this study was to evaluate whether a flow cytometric assay with the anthraquinone, DRAQ7, was a better alternative than the colorimetric MTT assay for measuring cell viability. MATERIALS AND METHODS: Two glioma cell lines (IPSB-18, U373) and 1 pancreatic cancer cell line (AsPC-1) were treated with 4 polyphenols, namely red grape seed extract, red clover extract, anthocyanin-rich extract and curcumin. Cell viability was assessed using MTT assay and DRAQ7 staining. RESULTS: Limitations of MTT assay included lack of sensitivity and interference with the structure and absorbance spectra of polyphenols. Also, DMSO was toxic to glioma cells. Microscopic observations of cells treated with polyphenols confirmed the range of IC(50) values evaluated by DRAQ7, but not by the MTT assay. CONCLUSION: DRAQ7 is a better alternative than MTT for measuring viability of glioma cells treated with brightly coloured polyphenols.

Background Diffuse gliomas have an increased biological aggressiveness across the World Health Organization (WHO) grading system. The implications of glioma grading on the primary motor cortex (M1)-corticospinal tract (CST) excitability is unknown. Objective To assess the excitability of the motor pathway with navigated transcranial magnetic stimulation (nTMS). Methods Retrospective cohort study of patients admitted for surgery with diffuse gliomas within motor eloquent areas. Demographic, clinical, and nTMS-related variables were collected. The Cortical Excitability Score (CES 0 to 2 according to the number of abnormal interhemispheric resting motor threshold (RMT) ratios) was calculated for patients where bilateral upper and lower limb mapping was performed. Results A total of 45 patients were included: 9 patients had a low-grade glioma and 36 patients had a high-grade glioma. The unadjusted analysis revealed an increase in the latency of the motor evoked potential of the lower limb with an increase of the WHO grade (P = .038). The adjusted analysis confirmed this finding (P = .013) and showed a relation between the increase in the WHO and a decreased RMT (P = .037) of the motor evoked responses in the lower limb. When CES was calculated, an increase in the score was related with an increase in the WHO grade (unadjusted analysis-P = .0001; adjusted analysis-P = .001) and in isocitrate dehydrogenase (IDH) wild-type tumors (unadjusted analysis-P = .020). Conclusion An increase in the WHO grading system and IDH wild-type tumors are associated with an abnormal excitability of the motor eloquent areas in patients with diffuse gliomas.

Background Lesions within the primary motor cortex (M1) and the corticospinal tract (CST) represent a significant surgical challenge with a delicate functional trade-off that should be integrated in the overall patient-centered treatment plan.Methods Patients with lesions within the M1 and CST with preoperative cortical and subcortical mapping (navigated transcranial magnetic stimulation [nTMS] and tractography), intraoperative mapping, and intraoperative provisional histologic information (smear with and without 5-aminolevulinic acid [5-ALA]) were included. This independently acquired information was integrated in a decision-making process model to determine the intraoperative extent of resection.Results A total of 10 patients (6 patients with metastatic precentral tumor; 1 patient with grade III and 2 patients with grade IV gliomas; 1 patient with precentral cavernoma) were included in the study. Most of the patients (60%) had a preoperative motor deficit. The nTMS documented M1 invasion in all cases, and in eight patients, the lesions were embedded within the CST. Overall, 70% of patients underwent gross total resection; 20% of patients underwent near-total resection of the lesions. In only one patient was no surgical resection possible after both preoperative and intraoperative mapping. Overall, 70% of patients remained stable postoperatively, and previous motor weakness improved in 20%.Conclusion The independently acquired anatomical (anatomical MRI) and functional (nTMS and tractography) tests in patients with CST lesions provide a useful guide for resection. The inclusion of histologic information (smear with or without 5-ALA) further allows the surgical team to balance the potential functional risks within the global treatment plan. Therefore, the patient is kept at the center of the informed decision-making process.

Central nervous system lymphoma (CNSL) represents one of the most aggressive forms of extranodal lymphoma. The gold standard for CNSL diagnosis remains the stereotactic biopsy, with a limited role for cytoreductive surgery that has not been supported by historical data. Our study aims to provide a comprehensive overview of neurosurgery’s role in the diagnosis of systemic relapsed and primary CNSL, with an emphasis on the impact on management and survival. This is a single center retrospective cohort study with data collected between August 2012 and August 2020, including patients referred with a potential diagnosis of CNSL to the local Neuro-oncology Multidisciplinary Team (MDT). The concordance between the MDT outcome and histopathological confirmation was assessed using diagnostic statistics. A Cox regression is used for overall survival (OS) risk factor analysis, and Kaplan–Meier statistics are performed for three prognostic models. The diagnosis of lymphoma is confirmed in all cases of relapsed CNSL, and in all but two patients who underwent neurosurgery. For the relapsed CNSL group, the highest positive predictive value (PPV) is found for an MDT outcome when lymphoma had been considered as single or topmost probable diagnosis. Neuro-oncology MDT has an important role in establishing the diagnosis in CNSL, not only to plan tissue diagnosis but also to stratify the surgical candidates. The MDT outcome based on history and imaging has good predictive value for cases where lymphoma is considered the most probable diagnosis, with the best prediction for cases of relapsed CNSL, questioning the need for invasive tissue diagnosis in the latter group.

Intramedullary spinal cord tumours (IMSCTs) are comparatively rare neoplasms. We present a single-centre clinical case series of adult patients with surgically managed IMSCTs.We performed a retrospective analysis of electronic patient records in the time period spanning July 2010 to July 2021. All adult patients that had undergone surgical management for IMSCTs were eligible for inclusion. Baseline and post-operative clinical and radiological characteristics, along with follow-up data, were assessed. We also performed a literature review with a focus on surgical outcomes for IMSCTs.Sixty-six patients matched our selection criteria, with a median age of 42 years (range 23-85). Thirty-four ependymomas, 17 haemangioblastomas, 12 astrocytomas, 2 lymphomas and 1 teratoma were included. Statistical analysis yielded several significant findings: IMSCTs spanning a greater number of vertebral levels are significantly associated with poor McCormick outcomes (p = 0.03), presence of gait disturbance before surgery is significantly associated with poor outcome for both post-operative McCormick and Nurick scores (p = 0.007), and radicular pain present pre-operatively is significantly associated with a good post-operative McCormick score (p = 0.045). Haemangioblastomas are significantly more likely to have a clear intra-operative dissection plane compared to ependymomas and astrocytomas (p = 0.009). However, astrocytomas have a significantly higher prevalence of good McCormick outcomes compared to ependymomas and haemangioblastomas (p = 0.03).Histological diagnosis, cranio-caudal extent of the tumour and the presence or absence of baseline deficits-such as gait impairment and radicular pain-are significant in determining neurological outcomes after surgery for IMSCTs.

Deep-seated brain tumours represent a unique neurosurgical challenge as they are often surrounded by eloquent structures. We describe a minimally invasive technique using tubular retractors and intraoperative neurophysiology monitoring for open biopsy of a deep-seated lesion surrounded by the corticospinal tract. We used preoperative functional mapping with diffusion tensor imaging tractography and navigated transcranial magnetic stimulation to identify a safe surgical corridor. We also used 5-Aminolevulinic Acid induced fluorescence to identify the lesion intraoperatively and optimize tissue samples obtained for histopathological diagnosis. We found the use of these tools improved the safety of surgery and reduced the risk of surgical morbidity.

Objectives: The study aims to evaluate therapeutic strategies in the management of craniospinal tumours in pregnant patients and the factors that influence the management along with their influence on maternal & foetal outcomes. Materials and Methods:A retrospective single-centre cohort study was performed at a tertiary neurosurgical referral centre. Pregnant patients referred to neuro-oncology multidisciplinary meeting (MDM) with craniospinal tumour were included. Ten-year patient data were collected from hospital records and neuro-oncology MDM outcomes. A systematic review was performed on the available literature in PubMed as per PRISMA guidelines. Results:Thirty-three patients were identified with a mean age of 31 years. 91%(n=30) had cranial lesions and 9%(n=3) had spinal lesions. Most of the patients had WHO Grade I/II tumours. 33.3% underwent surgery when pregnant whilst in 24.2% this was deferred until after the due date. 27.2% patients did not require surgical intervention and were followed up with serial imaging in the MDM. Left Lateral/park bench position was the preferred position for the spinal and posterior fossa lesions. Systematic review identified 26 eligible articles. Treatment algorithms are proposed addressing the therapeutic strategy for management of cranio-spinal tumours during pregnancy and the challenges for maternal and foetal outcomes were tabulated. Conclusions:Craniospinal tumours presenting in pregnancy are challenging. The surgical management needs to be tailored individually and as part of a multidisciplinary team approach. Maternal and foetal outcomes are to be considered during patient counselling.

Intraoperative neuromonitoring of motor functions experienced a dramatical revolution in the last years thanks to significant advances in anesthesiology procedures and both preoperative and intraoperative mapping techniques. Asleep, awake, and combined intraoperative mapping techniques were responsible for an improvement in the functional outcomes in neurosurgery, providing reliable and reproducible mapping of both projection and association fibers involved in motor control.We report inter-M1 cortico-cortical evoked potential (CCEP) recording during asleep resection of a bilateral parasagittal meningioma with intraoperative neuromonitoring and motor mapping.CCEPs were recorded between both M1 cortices with bipolar stimulations of both supplementary motor areas (10.5-11.5 μV).Here, we provide evidence of intraoperative mapping of commissural fibres involved in motor control in a patient with asleep technique as well as a review of the potential tracts involved in the connectivity underlying the motor function.

Intraoperative neuromonitoring of motor functions experienced a dramatical revolution in the last years due to significant advances in anaesthesiology procedures and both preoperative and intraoperative mapping techniques. Asleep, awake and combined intraoperative mapping techniques were responsible for an improvement in the functional outcomes in neurosurgery providing reliable and reproducible mapping of both projection and association fibres involved in motor control. Here, we provide evidence of intraoperative mapping of commissural fibres involved in motor control in a patient with asleep technique as well as a review of the potential tracts involved in the connectivity underlying the motor function.

Transsulcal minimally invasive parafasicular (TsMIP) approaches to brain tumor resection use tubular retractors to minimize iatrogenic brain injury. Dynamic cortical and subcortical continuous neurophysiological mapping facilitates safer resection of motor-eloquent tumors.To describe a new technique to address the challenge of combining TsMIP with tubular retractors and dynamic subcortical mapping using a single electrified stimulating microdebrider instrument.We adapted the NICO Myriad microdebrider with continuous monopolar stimulation electrification using high-frequency stimulation with the train-of-5 technique. We performed continuous subcortical mapping using this device and compared it with standard dynamic monopolar subcortical mapping using a suction stimulation device. We found no significant difference in recorded stimulation response.Using a single operating instrument that provides synchronous tumor resection and monopolar subcortical mapping with the NICO Brainpath tubular retractor, we observed increased degrees of movement, faster surgical resection times with an enlarged working channel down the retractor, and improved safety because the stimulating probe sits 2 mm deep to the resection window.We show that the adapted device is reliable and provides similar stimulation response as conventional subcortical mapping. We advocate the use of our adapted microdebrider in TsMIP tubular retractor approaches.

Surgery for meningiomas involving dural venous sinuses is challenging. We describe a case of a peritorcular meningioma involving major venous sinuses, which was removed using a venous sparing approach with the aid of intraoperative ultrasound. We found ultrasound to be a useful adjunct as it enabled us to get real-time information about the location of venous structures, their function and demonstrate dynamic changes in blood flow during surgery.

Background Patient-reported experience measures (PREMs) are a unique measure of experience of patients which can help address the quality of care of the patients. Objective Our aim of the study is to collect quality of care outcomes with our newly navigated transcranial magnetic stimulation patient-reported experience measure (nTMS-PREMs) questionnaire among neurosurgical patients undergoing nTMS. Methods A single-centre prospective nTMS-PREMs 19-item questionnaire study was performed between February 2018 and December 2018 on patient referred for nTMS at our hospital. The Data was analysed using Likert scale, linear and logistic regression using statistical software (STATA 13.0®). Results Fifty patient questionnaires were collected (30 males, 20 females, mean age of 47.6 ± 2.1 years) among which 74% of patients underwent both motor and language mapping with a mean duration of 103.3 ± 5.1 min. An overall positive response was noted from the results of the questionnaire, tiredness and anxiety being the common effects noted. Patients with the left-sided disease appreciated more the conditions provided in our laboratory (Q4, p = 0.040) and increasing age was related to less confidence and trust (Q6, p = 0.038) in the staff performing the exam. Younger patients tolerated nTMS better than older patients (> 65 years). PubMed literature search resulted in no relevant articles on the use of PREMs in nTMS patients. Conclusion nTMS is a well-tolerated non-invasive tool and nTMS-PREMS provides a promising role in identifying the unmet needs of the patients and improving the quality of their care.

Brain biopsies are required to establish a definitive histological diagnosis for brain lesions that have been identified on imaging in order to guide further treatment for patients. Various navigation systems are in use but little up to date evidence is available regarding the safety and accuracy of a frameless, electromagnetic technique to target brain lesions. Data was collected retrospectively on all patients that had brain biopsies at our institution from 01/01/2010 to 31/12/2017. Operation notes, neuropathology reports, and clinical notes on electronic patient record were used to determine whether biopsy of adequate identifiable abnormal tissue was achieved, whether a definitive diagnosis was established, any adverse events occurred, and if a repeat biopsy was carried out. Three hundred seventy-one AxiEM (Medtronic, Minneapolis, USA)-guided brain tumor biopsies were performed in this 8-year period. Three hundred forty-nine (94.07%) procedures provided definitive tissue diagnosis, 22 (5.93%) were non diagnostic; in 6 cases (1.62%), repeat biopsy was performed and adverse events which caused clinical compromise were observed in 4 patients (1.08%). The AxiEM is a fast, effective, and safe frameless and pinless neuronavigational system. It offers a high degree of accuracy required for the establishment of a definitive diagnosis, permitting optimal further treatment, and thus improving patient outcomes.

AIMS There is a gap in supporting patients with sexual relationships and intimacy. The aim of this study is to establish if patients with a brain tumour feel they are able to ask questions and concerns about sex, relationships and intimacy following diagnosis; is there an unmet need and how can this be addressed. METHOD An anonymous survey was sent to patients known to a neuro-oncology team. Questions were in relation to their experiences of sex relationships and intimacy. Patients were asked if they had concerns about changes in their relationships since their diagnosis. They were also asked for their comments on the subject so we can better understand how as a service we can improve to ensure holistic care. RESULTS There are 40 responses. The majority of respondents had concerns about their relationship since diagnosis and that their relationships have changed. 57% were concerned about a physical relationship with a partner/ future partners. 50% agreed their physical relationship had changed. 45% of people agreeing their emotional relationships have changed. 38 out of the 40 people questioned, had not asked their clinical team for advice about sex and relationships. 46% suggested clinicians initiating these conversations. CONCLUSION Sex relationships and intimacy are significant for most adult populations, encompassing connection with their loved ones, self esteem and psychological and emotional well-being. With brain tumour diagnosis this part of people’s lives can hugely impacted. Historically clinicians have found this a difficult subject to discuss. Further work is required to understand the barriers initiating this subject

AIMS Assess the impact of tubular retractor-assisted transsulcal minimal invasive parafascicular approaches(tsMIPS) in the cortical vascularization using indocianin green angiography(ICGA) during removal of deep-seated cerebral tumours. METHOD Single-centre prospective cohort study of patients with deep-seated lesions – distance to nearest sulcus > 10mm - where ICGA was performed. Zeiss FLOW800 Software was used to analyse the following variables - delay time, speed, time to peak and rise time - before and after insertion of the tubular retractor (NICO BrainPath). RESULTS 13 patients were enrolled. 60 regions-of-interest were analysed. The most common pathology was high grade glioma (69%). The average depth of tumours was 34,2mm (23– 45mm) and the time-under-retraction 166mins (45-280 mins). The most common vascular pattern before-after tubular retractor was: increase on the delay time, time to peak and rising time (present in 8 patients) and a decrease on the speed (present in 7 patients). Two patients had a mayor neurological deficit after the surgery. Both had the same flow pattern with an increase on the speed and decrease on the time to peak and rise time, the delay was indifference. CONCLUSION This is the first study assessing the impact of tubular retractor-assisted tsMIPS in cortical vascularization during deep-seated lesion resection. The most common cortical vascular pattern is: an increase on the delay time, time to peak and rising time and a decrease on the speed. The two patients who presented vascular injury shared the same pattern (increase on the speed, decrease on the time to peak and rise time, with indifference delay).

AIMS To describe the methods used to assess and monitor motor function during awake craniotomy surgery for tumour resection. METHOD A service review was carried out over 10 months. Patients with highly motor eloquent lesions – invasion of primary motor cortex or fronto-parietal connections involved in motor cognition – were included. Clinical notes were reviewed and summarised using descriptive analysis. Dexterity and grip strength were measured using 9-hole peg test and handheld dynameter pre/intra and post-operatively. Patient occupation/interests were reported to guide bespoke assessments to trial intra-operatively. RESULTS From April 2021 to January 2022, 13 patients (mean age 39.7 years, 4 female:10 male, 9 low grade:5 high grade gliomas) were included. Mean score 9-hole peg test 22.2sec pre-operatively, 30.6sec post-operatively; handheld dynameter 26.7kg pre-operatively, 18.4kg post-operatively. At discharge 5 of 7 impaired patients demonstrated motor improvement. For motor coordination, motor tasks used frequently included repetitive finger tapping, open/closed hand. Bespoke tasks included texting/writing, playing instruments, and computer games. Movement was closely monitored and verbal feedback given to the neurosurgeons throughout. With video analysis movement comparisons were made. CONCLUSION The role of physiotherapy in awake surgery is evolving to provide movement analysis for complex motor tasks such as upper limb sequencing and dexterity. A combination of standard and bespoke assessments have been trialled and their feasibility within surgery tested. A post-operative deterioration of motor function (power and cognition) is expected after surgery for highly eloquent motor gliomas. However, intraoperative motor assessment for motor cognition allows function preservation and potentiates its recovery.

Ki67 is a marker for proliferation of a given cell population. Low expression of Ki67 may be associated with a favourable outcome. We investigate how the proliferation index correlates with the location, morphology and behaviour of WHO grade II ependymomas with a single-centre cohort study of adult patients admitted for surgery of WHO grade II ependymomas between 2008 and 2018. Seventeen patients were included, seven had supratentorial and 10 had infratentorial tumours. Three patients died and eight had recurrent disease. Age, gender, location, extent of resection, chemotherapy, radiotherapy and histological markers were not associated with tumour progression. Both unadjusted and adjusted analysis confirmed a higher Ki67 index in male patients. Sensitivity analysis further supported the correlation between Ki67 and male gender. Ki67 may be sex specific but does not seem to correlate with survival and time to recurrence in this series.

The benefits of using 5-aminolevulinic acid (5-ALA) in resection of grade IV tumors have been extensively researched. However, few studies have investigated the use of 5-ALA in grade III gliomas.To discover whether 5-ALA provides significant benefit in assisting resection of grade III gliomas.A single-center, retrospective cohort study between January 2013 and January 2019 of adult patients with grade III gliomas. Patients were separated into a 5-ALA-guided surgery group (5-ALA-GS) and non-5-ALA-guided surgery group (non-5-ALA-GS). Primary outcome was overall survival (OS); secondary outcomes were both postoperative and 6-month performance status (PS6m), and extent of resection (EoR).Sixty-nine patients with grade III gliomas were included (39 and 30 patients in the 5-ALA-GS group and non-5-ALA-GS group, respectively). There was no significant difference in tumor characteristics between the groups. No significant difference was observed in OS (P = .072) and EoR (P = .609) between both the groups. In a subgroup of the 5-ALA-GS where gross total resection (GTR) was achieved, there was a better OS (P = .043). Significantly worse outcomes were seen postoperatively (P = .044) and at PS6m (P = .041) in the 5-ALA-GS group, mainly because of the poorer outcome in the subtotal resection subgroup.Despite the benefits of 5-ALA in grade IV glioma surgery, these benefits are limited to a smaller group of patients with grade III tumors where there is sufficient fluorescence to allow GTR. In this cohort of patients, 5-ALA use may result in worse neurological outcomes particularly when GTR is not feasible and therefore caution is warranted.

Aims Primary central nervous system lymphoma (PCNSL) is a rare form of non–Hodgkin lymphoma with exclusive manifestations in the central nervous system, leptomeninges and eyes. It forms around 5% of all primary brain tumours. It is an aggressive tumour which has a poor prognosis if left untreated. It is imperative that diagnosis is made timely so treatment can be started promptly. Therefore, we performed an audit looking into the speed of diagnostic process of PCNSL in our tertiary Neuro–oncology Unit. Method Single-centre retrospective review of PCNSL cases referred to a tertiary Neuro–Oncology Unit over a six month period from June to November 2020. Results A total of 1309 cases were discussed in the Neuro–oncology MDT meeting over the study period. Fourteen cases (6 male, 8 female; median age [range] 66 [59–83] years) were identified as highly likely PCNSL. Neuroimaging suggested PCNSL as the likely diagnosis in twelve patients. Twelve patients were started on steroids after CT or MRI brain scans. Nine patients had a surgical target and proceeded to have diagnostic brain biopsy. Two patients had different working diagnoses and three patients were deemed unsuitable for brain surgery. One patient required repeat brain biopsy. A tissue diagnosis was made in twelve patients. One patient deteriorated rapidly and one patient had a brain lesion that was deemed too high risk for surgery. The median time between neuroimaging and biopsy was 25 days. The median time taken from first investigation to the pathological confirmation of PCNSL was 36 days (range 6–86 days). Conclusion The chief reason for delay in diagnosis of PCNSL was that patients were started on steroids before diagnostic investigations were completed. Steroids caused the brain lesions to become smaller or disappear. Accordingly, time was needed to allow withdrawal of steroids before diagnostic investigations could be repeated. Diagnostic delays may have been exacerbated by logistical issues associated with COVID–19. We propose that there needs to be greater awareness of how early introduction of steroids can markedly delay the diagnosis of PCNSL.

Low-grade gliomas are a heterogeneous group with significant changes in their management during the last decade.To assess how our multidisciplinary team approach to the management of low-grade glioma has evolved over the past 10 years and its implications for outcomes.Retrospective single-center cohort study of adult patients with a pathologically confirmed diagnosis of World Health Organization grade II glioma between 2009 and 2018. Demographic, clinical, and pathologic data were collected.Ninety-five patients were included. There was a statistically significant difference in the surgical approach, with more patients having gross total resection (45.7% vs. 18.4%) and fewer patients having a biopsy (21.8% vs. 49.0%) (P = 0.002) after 2014. There was a significantly better overall survival after 2014 (2014, 16.3%; ≥2014, 0 deaths; P = 0.010) measured at the mean time of follow-up. The use of adjuvant chemotherapy (P = 0.045) and radiotherapy (P = 0.001) significantly decreased after 2014. A subgroup analysis showed that the impact of extent of surgical resection was the greatest for survival in the 1p19q noncodeleted tumors (P = 0.029) and for seizure outcomes in the 1p19q codeleted group (P = 0.018). There was no statistically significant increase in neurologic disability with more radical surgery, incorporating intraoperative neuromonitoring, as measured by modified Rankin Scale score (P0.05).More radical surgery was associated with increased survival, less need for postoperative adjuvant therapy and better seizure control, without significant morbidity. Molecular markers are useful tools for stratification of benefits after such surgery.

This paper retraces the fundamental achievements of Geoffrey Knight (1906–1994), a British neurosurgeon and a pioneer in the field of psychosurgery. His career developed in the 1950s and 1960s, when—following the unregulated practice of frontal lobotomies—strong criticism arose in the medical community and in the general public against psychosurgery. Geoffrey Knight's clinical research focused on identifying new, selective targets to limit the side effects of psychosurgery while improving the outcome of patients affected by mental disorders. Following the example of William Beecher Scoville, he initially developed restricted orbital undercutting as a less invasive alternative to standard frontal lobotomy. He then developed stereotactic subcaudate tractotomy, with the use of an original stereotactic device. Knight stressed the importance of the anatomy and neurophysiology of the structures targeted in subcaudate tractotomy, with particular regard to the fibers connecting the anterior cingulate region, the amygdala, the orbitofrontal cortex, and the hypothalamus. Of interest, the role of these white matter connections has been recently recognized in deep brain stimulation for major depression and anorexia nervosa. This is perhaps the most enduring legacy of Knight to the field of psychosurgery. He refined frontal leucotomies by selecting a restricted target at the center of a network that plays a crucial role in controlling mood disorders. He then developed a safe, minimally invasive stereotactic operation to reach this target. His work, well ahead of his time, still represents a valid reference on which to build future clinical experience in the modern era of neuromodulation for psychiatric diseases.

Background Grade I meningiomas are generally benign and non-invasive whereas Grade II (atypical) and Grade III (malignant) meningiomas tend to be invasive with a high risk of recurrence. SPARC, secreted protein, acidic and rich in cysteine, is a multifunctional glycoprotein which has been proposed to be a potential diagnostic marker of invasive meningiomas. There has been increased reporting of atypical meningiomas since the current World Health Organization (WHO) included brain invasion as a grading criterion for classification of these particular meningiomas. Materials and methods The aim of this study was to re-evaluate any correlation between immunohistochemical expression of SPARC in 34 meningiomas of various grades using the current classification (2016). We had previously classified these cases using the 2002 WHO criteria. Results There is no correlation between expression of SPARC and invasion in different grades of meningioma. Conclusion SPARC does not appear to be a good predictor of invasion in meningiomas.

Background: The novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had a drastic effect on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-economically diverse population. We also describe the strategies we adopted to meet these challenges. Methods: A prospective single centre cohort study including all patients referred to the acute neurosurgical service or the subspecialty multi-disciplinary teams (MDT) as well as all emergency and elective admissions during COVID-19 (18th March 2020-15th May 2020) compared to pre-COVID-19 (18th of January 2020-17th March 2020). Data on demographics, diagnosis, operation, and treatment recommendation/outcome were collected and analysed. Findings: Overall, there was a reduction in neurosurgical emergency referrals by 33·6% and operations by 55·6% during the course of COVID-19. There was a significant increase in the proportion of emergency operations performed during COVID-19 (75·2% of total, n=155) when compared to pre-COVID-19 (n=198, 43·7% of total, p

5-ALA is proven to be effective in high-grade glioma operative resection. The use of 5-ALA in WHO grade I lesions is still controversial. A 49-year-old lady was diagnosed in 2004 with a left temporal lobe lesion as an incidental finding; she was followed up clinically and radiologically. In 2016, the lesion showed contrast enhancement and she was offered surgical resection but given she is asymptomatic, she refused. In 2018, the lesion showed signs of transformation with ring contrast enhancement, increased vasogenic oedema and perfusion; the patient accepted surgery at that point. She had preoperative mapping by navigated transcranial magnetic stimulation and she had operative resection with 5-ALA. The tumour was bright fluorescent under Blue 400 filter—Zeiss Pentero 900©(Carl Zeiss Meditec)—and both bright fluorescence and pale fluorescence were resected. Postoperative MRI showed complete resection and histopathology revealed WHO grade I papillary glioneuronal tumour, negative for BRAF V600 mutation. WHO grade I papillary glioneuronal tumour may present as 5-ALA fluorescent lesions. From a clinical perspective, 5-ALA can be used to achieve complete resections in these lesions which, in most cases, can be curative. Electronic supplementary material The online version of this article (10.1007/s00701-020-04223-x) contains supplementary material, which is available to authorized users.