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BackgroundMeningiomas are the most common primary intracranial tumor in adults. Clinical care is currently guided by the World Health Organization (WHO) grade assigned to meningiomas, a 3-tiered grading system based on histopathology features, as well as extent of surgical resection. Clinical behavior, however, often fails to conform to the WHO grade. Additional prognostic information is needed to optimize patient management.MethodsWe evaluated whether chromosomal copy-number data improved prediction of time-to-recurrence for patients with meningioma who were treated with surgery, relative to the WHO schema. The models were developed using Cox proportional hazards, random survival forest, and gradient boosting in a discovery cohort of 527 meningioma patients and validated in 2 independent cohorts of 172 meningioma patients characterized by orthogonal genomic platforms.ResultsWe developed a 3-tiered grading scheme (Integrated Grades 1-3), which incorporated mitotic count and loss of chromosome 1p, 3p, 4, 6, 10, 14q, 18, 19, or CDKN2A. 32% of meningiomas reclassified to either a lower-risk or higher-risk Integrated Grade compared to their assigned WHO grade. The Integrated Grade more accurately identified meningioma patients at risk for recurrence, relative to the WHO grade, as determined by time-dependent area under the curve, average precision, and the Brier score.ConclusionWe propose a molecularly integrated grading scheme for meningiomas that significantly improves upon the current WHO grading system in prediction of progression-free survival. This framework can be broadly adopted by clinicians with relative ease using widely available genomic technologies and presents an advance in the care of meningioma patients.

Purpose: Povidone-iodine, or Betadine® (Atlantis Consumer Healthcare Inc., Bridgewater, NJ), is a commonly used agent for surgical site preparation. Although commonly used, it carries the risk of skin reactions, and multiple cases of intra-operative contact dermatitis and chemical burns have been reported. However, to our knowledge, there are currently no published cases of povidone-iodine-induced skin lesions in neurosurgical patients. Methods: A single-center retrospective chart review was performed to identify patients who developed scalp lesions secondary to chemical toxicity following neurosurgical procedures between October 1, 2021, and June 30, 2024. Results: Three patients were identified, ranging from 2.5 months to 14 years old. Two were positioned prone and the third in lateral decubitus. All patients’ heads were supported by a horseshoe headrest covered with a gel pad and wrapped in a cotton roll. For two patients, Reston™ foam (3M©, St. Paul, MN) was added on the horseshoe. Surgical sites were prepped with isopropyl alcohol, Betadine®, and chlorohexidine. Two patients had their heads intermittently lifted throughout the procedure. Lesions were identified immediately after returning the patient to the supine position in the operating room and steadily improved over the course of one to five months with local wound care. Conclusions: Careful preparation of the surgical site is an essential step in the prevention of surgical site infections. However, caution should be exercised during skin preparation to avoid pooling of povidone-iodine around dependent regions. Additional steps, such as scheduled head elevations and pressure dispersion, should be taken to mitigate factors contributing to these lesions. [ABSTRACT FROM AUTHOR]

Simple Summary: This systematic review examined 42 adult cerebellopontine angle (CPA) medulloblastoma (CPAMB) patients with individual patient data from 27 studies. The median age was 32 years. Patients commonly presented with headaches (81%), cranial neuropathy (90%), cerebellar dysfunction (79%), and nausea/vomiting (50%). Maximal safe resection was pursued, and a gross total resection was performed in 60% of cases. Most patients (93%) received adjuvant therapy, typically both radiotherapy and chemotherapy. Outcomes were promising, with median survival rates of 96%, 85%, and 85% at 1, 3, and 5 years, respectively. The recurrence rate was low (11%) at a median of 18 months' follow-up. The receipt of adjuvant therapy was significantly associated with better recurrence and survival outcomes. Medulloblastoma should be considered in the differential diagnosis of young adult patients with CPA lesions with radiographical features suggesting hypercellularity. Maximal safe resection and adjuvant craniospinal radiotherapy plus systemic therapy is an optimal management strategy. Objective: The aim of this study was to systematically review the existing individual patient data in the literature on adult cerebellopontine angle (CPA) medulloblastoma (MB) and characterize the patient presentation, management strategies used, and oncological outcomes of this rare entity to guide future clinical practice. Methods: Following PRISMA guidelines, a systematic review was conducted by searching PubMed, EMBASE, Web of Science, and Cochrane databases from inception to 19 June 2024. Studies regarding adult patients with histologically confirmed MB radiographically confirmed to be located in the CPA were included. Clinical data were synthesized, and predictors of outcomes were evaluated. Results: Twenty-seven studies with 42 adult CPAMB patients were included. The median age was 32 years (range: 19–56). Headaches (81%), cranial neuropathy (90%), cerebellar dysfunction (79%), and nausea/vomiting (50%) were typical presenting features. The predominant histological subtype was the classic variant. Maximal safe surgical resection was performed, most commonly using a retrosigmoid approach, and 60% of cases received a gross total resection. Most patients received adjuvant treatment (93%), typically chemoradiotherapy. The recurrence rate was 11% after a median of 18 months of follow-up. Relatively high survival rates of 96%, 85%, and 85% were observed at 1, 3, and 5 years, respectively. Patients who received adjuvant therapy had significantly better recurrence and greater overall survival outcomes. Conclusions: These results support the consideration of MB in young adult patients presenting with CPA tumors with radiographical features suggestive of hypercellularity and the utilization of a management strategy of maximal safe resection plus post-operative craniospinal irradiation along with chemotherapy to optimally treat these rare patients. [ABSTRACT FROM AUTHOR]

Objective While the transcondylar approach is technically challenging, it provides generous ventral and caudal exposure to the craniovertebral junction. This approach requires navigation around multiple eloquent neurovascular structures including the lower cranial nerves, vertebral artery and its branches, and the brainstem. Superficial exposure, including incision location and muscle dissection, can dramatically affect the surgical angle and maneuverability at depth. Methods We demonstrate the transcondylar approach in a step-by-step fashion in a formalin-embalmed, latex-injected cadaver head. Dissection within each layer of the suboccipital muscles was performed. A small cohort with an illustrative case is also included herein. Results The sternocleidomastoid (SCM) muscle was retracted anteriorly; the splenium capitis, semispinalis capitis, and longissimus capitis muscles were disconnected from the superior nuchal line and reflected inferomedially. The suboccipital muscle group was fully exposed. The superior and inferior oblique muscles were disconnected from the transverse process of C1. The superior oblique and the rectus capitis posterior major muscles were then dissected off the inferior nuchal line, and the suboccipital muscle group was retracted inferomedially en bloc. The greater auricular nerve was retracted laterally with the SCM, and the greater occipital nerve was retracted inferomedially with the suboccipital muscle group. Conclusion This technique avoids the obstructive muscle bulk that results from a myocutaneous approach while maximizing deep exposure. Understanding the detailed muscular anatomical relationship with the insertion location and suboccipital nerves is key to complete and safe extracranial dissection. Diligent dissection helps minimize postoperative pain and muscle spasm while optimizing the closure technique. [ABSTRACT FROM AUTHOR]

The presence of calcification is uncommon in pituitary adenomas, and often lends support to other diagnoses including craniopharyngioma. The majority of calcified pituitary adenomas are prolactin-secreting tumors. We report two patients with calcified macroprolactinomas, one that was treated medically with a biochemical response and partial tumor response, and one that was treated successfully via an endoscopic endonasal transsphenoidal approach. Suspected calcified prolactinomas can be initially managed medically as per standard treatment for typical prolactinomas; however, the presence of diffuse calcification may hinder tumor shrinkage. Tumors that are refractory to medical treatment can be safely managed with surgery. [ABSTRACT FROM AUTHOR]

Introduction: Congenital vomer agenesis is an extremely rare condition in which the vomer bone does not fully develop, which can lead to septal perforation. Case Report: We report two cases with a defect in the vomer bone in the posteroinferior portion of the septum, found accidentally while performing a pre-operative CT scan for nasal obstruction evaluation. They were diagnosed with congenital vomer agenesis. Conclusion: There are afew reports of vomer agenesis in literatures. By increasing usage of sinonasal endoscopic examination, we expect to address more cases in the future. [ABSTRACT FROM AUTHOR]

Background: Medical management is the first line of treatment for trigeminal neuralgia (TN). Patients with medically refractory TN may undergo a variety of invasive surgical interventions with varying success rates. Management of TN refractory to both medical and surgical intervention remains somewhat controversial., Objective: To assess the effectiveness of Gamma Knife radiosurgery (GKRS; Elekta Instruments AB) for medically refractory TN., Methods: A retrospective review was conducted for 57 cases (47 patients) who underwent GKRS for refractory TN at our institution between 2005 and 2018. TN pain outcomes were evaluated using the Barrow Neurological Institute (BNI) Pain Scale. A good outcome was defined by post-GKRS BNI score of I-III, whereas treatment failure was defined BNI score IV-V., Results: Of the total 57 GKRS procedures, 47 (82.5%) had good outcomes. A total of 22 patients (46.8%) experienced complete pain relief off medications (BNI I). The average time to pain relief was 30 d (range 1-120 d). Prior invasive surgical treatment for TN was not found to have a significant impact on GKRS outcomes (P = .32). Target and treatment volumes were not found to correlate significantly with GKRS outcomes (.47 and .47, respectively). Complications included 2 cases (4.2%) of facial numbness. A total of 37 patients (78.7%) did not have any additional invasive surgical interventions following GKRS treatment., Conclusion: GKRS is a safe and effective treatment modality for both medically and surgically refractory TN. Complete symptom relief was possible in patients with prior surgical or GKRS treatments. Recurrent symptoms following surgery or GKRS should not exclude a patient from future GKRS consideration., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Objective: Hypothalamic-pituitary-adrenal (HPA) axis dysfunction is a well-documented complication of transsphenoidal craniotomy (TSC) for sellar lesions. The authors aimed to assess their multidisciplinary approach to the diagnosis and treatment of postoperative hypocortisolemia utilizing conservative screening methods., Methods: The authors performed a retrospective review of 257 patients who underwent TSC for pituitary adenoma (PA) or Rathke cleft cyst (RCC) at the University of Southern California between 2012 and 2017. Patients with preoperative adrenal insufficiency, Cushing's disease, or < 3 months of postoperative follow-up were excluded. Patient demographics, pathology, tumor characteristics, and complications were recorded. Postoperative day 1 (POD1) morning serum cortisol was assessed in all patients. Hypocortisolemia on POD1 (serum cortisol < 5 μg/dl) prompted a 7 am cortisol level measurement on POD 2 (POD2). Clinical signs and symptoms of hypocortisolemia were consistently monitored. After two serum cortisol levels < 5 μg/dl, or one serum level < 5 μg/dl plus a high clinical suspicion for HPA dysfunction, high-risk patients received glucocorticoid supplementation., Results: Data on 165 patients were included in the analysis; there were 101 women (61.2%) and 64 men (38.7%). Preoperative diagnoses included nonfunctional adenoma (n = 97, 58.7%), growth hormone-secreting adenoma (n = 37, 22.4%), RCC (n = 18, 10.9%), prolactinoma (n = 8, 4.8%), and other (n = 5, 3.0%). One hundred thirty-eight patients (63.0%) had either suprasellar extension or cavernous sinus invasion. POD1 hypocortisolemia was diagnosed in 8 patients (4.8%). Of these patients, 2 (1.2%) were clinically asymptomatic and had normalized POD2 cortisol levels. Six patients (3.6%) had clinical symptoms and POD2 cortisol levels confirming HPA axis deficiency. Of these 6 patients treated with early glucocorticoid replacement, 2 patients recovered HPA axis function during follow-up, making the incidence of new, permanent HPA axis deficiency 2.5%., Conclusions: In the authors' institutional review, all patients warranting postoperative glucocorticoid replacement had both complicated surgical courses and associated clinical symptoms of hypocortisolemia. The authors' algorithm of withholding steroids until patients demonstrate clear evidence of postoperative hypocortisolemia is safe and clinically efficacious. Their data further suggest that routine postoperative cortisol screening may not be necessary following an uncomplicated operative resection, with gland preservation and the absence of clinical symptoms indicative of HPA dysfunction.