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Brain metastasis represents the most common intracranial tumor. Surgery has a key role in patients with an unknown primary, solitary site, large intracranial lesion, or those with neurologic symptomatology due to associated vasogenic edema and mass effect. There is also a resurgence in interest in biopsy or resection in patients with actionable alterations with discordant responses to targeted therapy or those proceeding to immunotherapy to reduce corticosteroid requirements. Moreover, advancements in radiotherapy have led to several options in patients with resectable brain metastasis including postoperative whole-brain radiotherapy, postoperative stereotactic radiosurgery (SRS), preoperative SRS, intraoperative radiotherapy, and CNS brachytherapy.

Digital, Objective. To review the scientific publications reporting vagal nerve somatosensory-evoked potential (VSEP) findings from individuals with brain disorders, and present novel physiological explanations on the VSEP origin. Methods. We did a systematic review on the papers reporting VSEP findings from individuals with brain disorders and their controls. We evaluated papers published from 2003 to date indexed in PubMed, Web of Science, and Scielo databases. We extracted the following information: number of patients and controls, type of neural disorder, age, gender, stimulating/recording and grounding electrodes as well as stimulus side, intensity, duration, frequency, and polarity. Information about physiological parameters, neurobiological variables, and correlation studies was also reviewed. Representative vignettes were included to add support to our conclusions. Results. The VSEP was studied in 297 patients with neural disorders such as Parkinson’s disease (PD), Alzheimer’s disease, vascular dementia, mild cognitive impairment, subjective memory impairment, major depression, and multiple sclerosis. Scalp responses marked as the VSEP showed high variability, low validity, and poor reproducibility. VSEP latencies and amplitudes did not correlate with disease duration, unified PD rating scale score, or heart function in PD patients nor with cerebrospinal fluid β amyloid, phosphor-τ, and cognitive tests from patients with mental disorders. Vignettes demonstrated that the VSEP was volume conduction propagating from muscles surrounding the scalp recording electrodes. Conclusion. The VSEP is not a brain-evoked potential of neural origin but muscle activity induced by electrical stimulation of the tragus region of the ear. This review and illustrative vignettes argue against assessing the parasympathetic system using the so-called VSEP., Ciencias Médicas y de la Salud

The purpose of this study was to critically analyze the risk of unplanned readmission following resection of brain metastasis and to identify key risk factors to allow for early intervention strategies in high-risk patients. We analyzed data from the Nationwide Readmissions Database (NRD) from 2010–2014, and included patients who underwent craniotomy for brain metastasis, identified using ICD-9-CM diagnosis (198.3) and procedure (01.59) codes. The primary outcome of the study was unplanned 30-day all-cause readmission rate. Secondary outcomes included reasons and costs of readmissions. Hierarchical logistic regression model was used to identify the factors associated with 30-day readmission following craniotomy for brain metastasis. During the study period, 44,846 index hospitalizations occurred for patients who underwent resection of brain metastasis. In this cohort, 17.8% (n = 7,965) had unplanned readmissions within the first 30 days after discharge from the index hospitalization. The readmission rate did not change significantly during the five-year study period (p-trend = 0.286). The median per-patient cost for 30-day unplanned readmission was $11,109 and this amounted to a total of $26.4 million per year, which extrapolates to a national expenditure of $269.6 million. Increasing age, male sex, insurance status, Elixhauser comorbidity index, length of stay, teaching status of the hospital, neurological complications and infectious complications were associated with 30-day readmission following discharge after an index admission for craniotomy for brain metastasis. Unplanned readmission rates after resection of brain metastasis remain high and involve substantial healthcare expenditures. Developing tools and interventions to prevent avoidable readmissions could focus on the high-risk patients as a future strategy to decrease substantial healthcare expense.

BACKGROUND Providing the standard of care to patients with glioblastoma (GBM) during the novel coronavirus of 2019 (COVID-19) pandemic is a challenge, particularly if a patient tests positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Further difficulties occur in eloquent cortex tumors because awake speech mapping can theoretically aerosolize viral particles and expose staff. Moreover, microscopic neurosurgery has become difficult because the use of airborne-level personal protective equipment (PPE) crowds the space between the surgeon and the eyepiece. However, delivering substandard care will inevitably lead to disease progression and poor outcomes. OBSERVATIONS A 60-year-old man with a left insular and frontal operculum GBM was found to be COVID-19 positive. Treatment was postponed pending a negative SARS-CoV-2 result, but in the interim, he developed intratumoral hemorrhage with progressive expressive aphasia. Because the tumor was causing dominant hemisphere language symptomatology, an awake craniotomy was the recommended surgical approach. With the use of airborne-level PPE and a surgical drape to protect the surgeon from the direction of potential aerosolization, near-total gross resection was achieved. LESSONS Delaying the treatment of patients with GBM who test positive for COVID-19 will lead to further neurological deterioration. Optimal and timely treatment such as awake speech mapping for COVID-19–positive patients with GBM can be provided safely.

Intracranial hypotension (IH) is a relatively common condition associated with low cerebrospinal (CSF) pressure. The most typical symptom is orthostatic headache, although neurological deficits and changes in the level of consciousness, such as encephalopathy, stupor, and coma, may also occur. Uncomplicated CSF hypotension headaches generally resolve with rest, hydration, and analgesia. However, persistent cases may require an epidural blood patch (EBP) for resolution. Our report presents the case of a 50-year-old male with a history of intravenous (IV) drug abuse, positive for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) antibodies, who was admitted for new-onset headache and brain magnetic resonance imaging (MRI) findings suggesting CSF hypotension. The patient subsequently developed altered mental status with agonizing respirations, prompting intubation and admission to the intensive care unit (ICU) with neurosurgery consult. The initial exam revealed fixed and dilated pupils, suggestive of severe IH with brain herniation and the decision was made to proceed with an emergent intrathecal infusion with intraparenchymal intracranial pressure (ICP) monitoring, combined with EBP. A substantial clinical improvement was noted following the procedure. Within 45 minutes, the patient’s mental status improved to normal and pupillary dilation and areflexia were no longer observed. While the procedure may need to be repeated in cases of late deterioration, this report provides evidence that intrathecal bolus saline infusion with simultaneous ICP monitoring may be considered an effective measure to treat extreme cases of IH with associated brain herniation. If performed in a timely fashion, improvement of ICP numbers, and clinical resolution can be quite rapid.

Background Cardiac myxomas, the most common primary cardiac tumors, are generally benign neoplasms. Primary cardiac lymphoma is a rare cardiac malignancy with a very poor prognosis. Here we present a case of a cardiac myxoma with cerebral metastases and chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) arising within the cerebral metastases. Case description A 62-year-old man, who presented with symptoms of multiple transient ischemic attacks, was found to have a left atrial myxoma. Twelve months after excision of the myxoma, the patient experienced a recurrence of neurologic symptoms. Brain magnetic resonance imaging revealed multiple hemorrhagic masses. Craniotomy was performed to resect the lesions. Histopathologic examination confirmed cardiac myxoma metastases and a small lymphocytic infiltrate within the tumor consistent with CLL/SLL. Conclusion Including the present case, there are 27 cases of cardiac myxoma cerebral metastases and 22 cases of lymphomas arising within myxomas. The present case is the first known instance of both entities in the same patient. There is no standard management for either cardiac myxoma metastases or lymphoma within a myxoma. For both diseases, surgical excision is the primary treatment modality, but postoperative chemotherapy and/or radiation have been attempted. Myxomas may create a chronic inflammatory state that could lead to the development of CLL/SLL.

Anterior communicating artery (ACoA) aneurysms are among the most common intracerebral aneurysms. Complications of ACoA aneurysm include subarachnoid hemorrhage, which may occur spontaneously or as a result of trauma. While prognosis of microsurgical clip ligation is excellent, iatrogenic afferent pupillary defect secondary to mechanical compression of the optic nerve by the clips is a known complication. Our report presents a case of a 59-year-old female status post resection of a pituitary macroadenoma one year ago with a three- to four-week history of progressively worsening headache found to have a 6.5 x 5.4 mm wide neck and irregularly dysplastic aneurysmal dilation of the ACoA. During the operation, two of the longer clips appeared to be touching the optic nerve and we utilized a clip suspension technique to relieve compression. This gently elevated and suspended the two clips up to the dura, allowing for a 2 mm gap between the optic nerve and clips. This maneuver relieved mechanical compression against the optic nerve and potentially mitigated the need for surgical re-exploration in the future.

PURPOSE/OBJECTIVE(S) Stereotactic radiosurgery (SRS) is increasingly used in brain metastasis patients. However, the impact of the timing on tumor volume change and tumor anatomical displacement between the diagnostic and treatment planning imaging is not well studied. MATERIALS/METHODS Consecutive patients diagnosed with brain metastases and treated with SRS between July, 2017 and June, 2020 were evaluated. Only patients who underwent an institutionally standardized diagnostic MRI (MRI-1) and a treatment planning MRI (MRI-2) with identical imaging parameters were included. The impact of histology, inter-scan interval, lesion location, volume and size were evaluated on final lesion size, volume and anatomic displacement. Correlations were assessed using Kendall's rank correlation. The Kruskal Wallis rank sum test was used for all other comparisons. RESULTS We included 101 eligible patients (531 lesions) with median inter-scan interval of 8 days (range: 1-42); 50% were NSCLC and 25% breast cancer. The three most common locations of lesions were the frontal (181 lesions, 34%), temporal (96, 18%), cerebellar (91, 17%) lobes. Median MRI-1 diameter and volume were 0.50 cm (Range: 0.23-0.89 cm) and 0.06 cm3 (Range: 0.01-4.62 cm3), respectively. Median percentage change in lesion diameter and volume were +9.5% (Range: -8.4% to +61.2%) and +20% (Range: -20% to +200%), respectively. Overall, there was a statistically significant change in percent tumor volume change between MRI-1 to MRI-2 (P = 0.01). Directional displacements exceeded 1 mm in 18 (3%) lesions in right to left (RL), 28 (5%) superior to inferior (SI), and 25 (4.7%) anterior to posterior (AP) directions. Overall, 355 (67%) lesions had any displacement in at least 1 direction between MRI-1 and MRI-2 and 205 (38%) in all 3 directions. Median lesion centroid displacement was 0.48 mm (0.10-3.09 mm) and was larger than 1 mm in 66 (12%) lesions. Differences were also observed across tumor histologies (P = 0.01); melanoma brain metastases had the largest magnitude changes. Tumor displacement also differed across various histologies with largest displacement in renal cell carcinoma metastases (P < 0.001). Magnitude of displacement was also significantly associated with tumor location (P = 0.03) with the largest displacement in parietal lobe lesions. Across all lesions, there was a difference in tumor size change in patients treated on corticosteroids (P = 0.01). CONCLUSION Volumetric and positional changes can occur during the planning process for SRS and are histology and location specific. Additional analyses are key to understanding the impact of each of these variables, corticosteroids, and systemic therapy to better understand and model tumor dynamics. AUTHOR DISCLOSURE T. Kutuk: None. R.P. Tolakanahalli: None. A. Williams: None. M.C. Tom: Research Grant; Blue Earth Diagnostics. J.D. Vadhan: None. H. Appel: None. M.D. Hall: Research Grant; Florida Department of Health; Proton Collaborative Group (PCG) Executive Council. D. Wieczorek: None. S.D. Davis: None. M.W. McDermott: Consultant; Stryker, Diende. V. Siomin: None. M.D. Chuong: Research Grant; ViewRay, AstraZeneca. Honoraria; ViewRay, Sirtex, Accuray. Speaker's Bureau; ViewRay, Sirtex, Accuray. Advisory Board; ViewRay, Advanced Accelerator Applications. Travel Expenses; ViewRay, AstraZeneca, Accuray; Particle Therapy Cooperative Group. Manages the operations and activities within the proton center; Miami Cancer. M.P. Mehta: None. A. Gutierrez: Honoraria; ViewRay, Elekta. R. Kotecha: None.

Background Although the classic radiobiologic principles of radiotherapy are well understood, the unique effects of the large fractional does that characterize stereotactic radiotherapy (SRT), specifically in terms of antitumor immune cellular processes, vascular damage, tumor necrosis, and apoptosis on brain metastasis have yet to be adequately demonstrated. The objective of this study is to provide the first in-human evaluation of the biological effects of SRT in resected brain metastasis. Methods All paired primary tumors and metastases for patients who underwent dose-escalated preoperative SRT followed by resection were evaluated for tumor necrosis using hematoxylin-eosin staining. T cells (CD3+, CD4+, CD8+), natural killer cells (CD56+), vessel density (CD31+), and apoptotic factors (caspase-3) were determined by immunohistochemical analysis. Results Fifteen patients with brain metastases from solid tumors received a median preoperative SRT dose of 18 Gy (range: 15–18 Gy) in 1 fraction, with 2 patients receiving 27–30 Gy in 3–5 fractions, followed by resection within a median interval of 90 hours (Range: 17.1–260 hours). The rate of necrosis was found to be significantly higher in irradiated brain metastases than in non-irradiated primary tumor samples (mean paired difference: 30.47, SD: 29.28, p=0.001). A decrease in all immunomodulatory cell populations was found in irradiated metastasis: CD3 (mean paired difference -19.4, SD: 31.7, p=0.03), CD4 (-10.0, SD: 20, p=0.01), and CD8 (-17.4, SD: 22.1, p=0.008). While irradiated samples had numerically lower CD 31+, CD 56+, and caspase-3 scores, the difference was not statistically significant. Time interval from SRT to surgery had no effect on these parameters. Conclusions There is complex interplay between tumor-associated cells and the unique radiobiological effects of SRT on tumor tissue. Although time interval from SRT to surgery was associated with increased tumor necrosis, differences in immunomodulatory factors may be multifactorial, including concurrent corticosteroids or the immunosuppressive effect of SRT.

Background: The purpose of the presented work is to evaluate the last decade’s experience in surgical management of central neurocytoma (CN) and elucidate on the treatment strategies and new options. Methods: The current series consists of the remaining 125 patients (70 females and 55 males) operated on during the past decade from 2008 to 2018. Most tumors were resected through transcortical (n = 76, 61%), or transcallosal (n = 40, 32%) approaches. In 5 (4%) patients with predominantly posterior location of the tumor, non-dominant superior parietal lobule approach was utilized. Both approaches (transcortical + transcallosal) were used in 4 (3%) of cases. Seven consecutive patients with large CN underwent prophylactic intraventricular stenting to prevent hydrocephalus. Results: Gross total resection was achieved in 45 patients (36%), subtotal resection (STR) in 40 (32%) cases. After surgery, 63 (50%) patients had neurocognitive problems, including disorientation, attention deficit, global amnesia, short-term memory deficits, and perceptual motor and social cognition problems. A total of 26 patients (21%) had postoperative hemorrhage in the resection bed. Obstructive hydrocephalus was noted in 25 (20%) patients. The entrapment of the occipital and/or temporal horns was observed in seven cases. None of the seven patients with prophylactic intraventricular stents required shunting. Conclusion: Although high rates of gross total or STR can be expected, the mortality and morbidity remain significant even in the modern neurosurgical era. Prophylactic intraventricular stenting in patients with large posteriorly located tumors with hydrocephalus may prevent ventricular entrapment and shunting. The main risk factors for recurrence are presence of residual disease and Ki-67 index over 5%. Recurrent symptomatic tumors should be treated surgically, whereas asymptomatic progression can be managed with stereotactic radiosurgery. Both treatment modalities are associated with low risk of complications and high tumor control rates.

OBJECTIVE Up to 30% of cancer patients will develop brain metastasis during the course of their systemic disease with a significant proportion undergoing resection of at least one lesion. The objective of the present study was to characterize the rates, predictors, and costs of 30-day readmissions following craniotomy for brain metastases using a nationally representative database. METHODS This study was a retrospective analysis of data from the Nationwide Readmissions Database (NRD) from 2010–2014. We included patients who underwent craniotomy for brain metastasis, identified using ICD-9-CM diagnosis (198.3) and procedure (01.59) codes. The primary outcome of the study was unplanned 30-day all-cause readmission rates. Secondary outcomes included predictors and costs of readmissions. RESULTS During the study period, there were 44,846 index hospitalizations for patients who underwent resection of brain metastasis. Among this cohort, 17.8% (n=7,965) had unplanned readmissions within the first 30 days after discharge from the index hospitalization. The readmission rate did not change significantly during the study period (P=0.286). The odds of unplanned readmission were significantly greater in patients with thromboembolic complications (aOR, 1.53; 95% CI: 1.18–2.01), patients with Elixhauser comorbidities >3 (aOR, 1.35; 95% CI: 1.22–1.50), male patients (adjusted odds ratio [aOR], 1.29; 95% CI: 1.17–1.42), patients with an initial length of stay ≥5 days (aOR, 1.02; 95% CI: 1.01–1.03). The median per-patient cost for 30-day unplanned readmission was $11,109 and this accounted for a total cost of $132.1 million during the study period. CONCLUSIONS Unplanned readmissions after resection for brain metastases involve substantial healthcare expenditures. Though there have been many interventions for improving surgical quality, post-operative care, and cost metrics, unplanned readmission rates have not changed. Key patient-specific variables and high rates of comorbidities should be considered to focus our efforts on patient selection for resection, and for strengthening existing interventions for high-risk patients.

Background: Low-grade gliomas (LGG) are described by the World Health Organization as Grades I and II. Among LGGs, the most common primary brain tumor is pilocytic astrocytoma (PA) and carries an excellent prognosis when treated with complete surgical resection. Cases, in which this is not possible, are associated with less favorable outcomes and worse progression-free survival. Case Description: This report describes a case of a 22-year-old male, who presented with progression of a primary brainstem tumor previously treated with stereotactic radiosurgery and chemotherapy. Patient underwent surgical exploration and was diagnosed with juvenile PA, but debulking was limited by the very dense and fibrous tumor. Complete surgical resection was not possible at this time. Despite efforts to treat with chemotherapy, the patient presented a year later with clinical deterioration and severe neurologic deficits, prompting surgical re-exploration. During the second operation, the tumor was found to have undergone very significant softening in consistency, allowing for gross total resection (GTR) Conclusion: Aggressive treatment of brainstem LGG should be pursued whenever possible, given its generally favorable prognosis. Repeat microsurgical resection, even with a different approach, might be reasonable and safe. Finally, chemotherapy may be associated with changes in the tumor consistency that can render previously unresectable lesions amenable to successful aggressive resection.

Purpose Choroid plexus metastases (CPM) are uncommon lesions. Consequently, optimal management of CPM is uncertain. We summarize our experience with stereotactic radiosurgery (SRS) of CPM. Methods and Materials Sixteen consecutive patients with presumed CPM treated with SRS between 1997 and 2007 were examined. Twelve were men with a median age at diagnosis of CPM of 61.9 ± 9.9 years; 14 had metastases from renal cell carcinoma (RCC). All patients had controlled primary disease at the time of treatment for CPM. Four patients with RCC and 1 with non–small-cell lung cancer had undergone whole-brain radiotherapy (WBRT) previously and 2 had received SRS to other brain metastases. The disease-free interval from the primary diagnosis to CPM diagnosis averaged 39.3 ± 46.2 months (range, 1.0–156.3). Five patients were asymptomatic; of the remaining 11, none had symptoms related to CPM. All presented with a single CPM. Results Average maximum diameter of the CPMs was 2.0 ± 1.0 cm (range, 0.9–4.1 cm); mean volume was 2.4 ± 2.6 cm 3 (range, 0.2–9.3). Median SRS dose was 24 Gy to the 53% isodose line (range, 14–24 Gy). Survival after SRS to the CPM was 25.3 ± 23.4 months (range, 3.2–101.6). Patients in Recursive Partitioning Analysis (RPA) class I ( n = 10) had improved survival compared to those in class II ( n = 6), as did those with better GPA scores. There were no local failures. After SRS, 1 patient underwent WBRT, 3 patients had one, and another had two subsequent SRS treatments to other brain lesions. Of the 14 patients who have died, 11 succumbed to systemic disease progression, 2 to progressive, multifocal central nervous system disease, and 1 to systemic disease with concurrent, stable central nervous system disease. There were no complications related to SRS. Conclusions Most CPMs are associated with RCC. SRS represents a safe and viable treatment option as primary modality for these metastases, with excellent outcomes.

Leptomeningeal disease (LMD) represents a diffuse form of central nervous system metastatic disease that is often associated with poor quality of life and prognosis. Our objective was to compare the incidence of LMD in patients with posterior fossa metastases (PFM) following stereotactic radiosurgery (SRS) versus surgical resection.The medical records of 93 patients aged 57.9 +/- 10.8 years (mean +/- SD) with PFM treated at the Cleveland Clinic from 1995 to 2001 were analyzed retrospectively. Treatments consisted of surgery with whole brain radiation therapy (WBRT) or SRS with or without WBRT. The impact of age, Karnofsky performance status (KPS) at presentation, Radiation Therapy Oncology Group, recursive partitioning analysis (RPA) class, status of extracranial disease, number, size, volume, pathology of brain metastases and steroid use were studied using univariate and multivariate analyses.There were 80 evaluable patients (10 lost to follow-up and three excluded for supratentorial surgery with subsequent LMD). LMD occurred after the surgical removal of the PFM in 9 of 18 patients (50%), whereas LMD occurred after SRS in 4 of 62 patients (6.5%) (p = 0.0028). Multivariate analysis also showed that patients who had surgery were more likely to develop LMD compared to patients treated with SRS (p = 0.0024). Patients had a median KPS decline of 30 points after LMD was diagnosed. There was no statistically significant difference in survival of patients with LMD and the rest of the patients (13.5 vs. 11.7 months, p = 0.7659). Patients treated surgically had significantly larger lesions (3.43 +/- 0.74 vs. 1.96 +/- 0.95 cm maximum diameter, p0.0001). All surgical patients belonged to RPA class II at diagnosis. Their survival was not different from the RPA class II patients in the SRS group. Surgery and SRS had comparable complication rates (8.1% vs. 5.6%, p = 0.99), although the surgical complications were more serious (e.g. hemorrhage, CSF leak). The duration of steroid use was longer after SRS compared to surgery (2.1 +/- 3.6 vs. 1.3 +/- 2.4 months); however, the difference was not statistically significant. Myopathy and psychosis in one patient after SRS, were the only steroid-related complications. There was no statistically significant association between the primary tumor type and the presence of LMD.In this retrospective analysis of patients with PFM, SRS was associated with a lower incidence of LMD than was surgery. Although LMD was associated with rapid and considerable decline in the quality of life, it did not influence the overall survival. SRS was associated with less serious complications than surgery. Surgery in this study was performed on patients with larger lesion sizes and a trend toward poorer initial performance status, which could bias these results. A prospective study directly comparing surgery and SRS and further evaluating the significance of LMD in PFM is warranted.

Background S100beta protein is expressed constitutively by brain astrocytes. Elevated S100beta levels in cerebrospinal fluid and serum reported after head trauma, subarachnoid hemorrhage, and stroke were correlated with the extent of brain damage. Because elevated serum S100beta also was shown to indicate blood-brain barrier (BBB) dysfunction in the absence of apparent brain injury, it remains unclear whether elevation of serum levels of S100beta reflect BBB dysfunction, parenchymal damage, or both. Methods The authors conducted a prospective study of serum S100beta levels in six patients who underwent hyperosmotic BBB disruption (BBBD) with intraarterial chemotherapy for primary central nervous system lymphoma. In addition, 53 serum S100beta samples were measured in 51 patients who had a variety of primary or metastatic brain lesions at the time of neuroimaging. Results S100beta was correlated directly with the degree of clinical and radiologic signs of BBBD in patients who were enrolled in the hyperosmotic study. In patients with neoplastic brain lesions, gadolinium enhancement on a magnetic resonance image was correlated with elevated S100beta levels (n = 45 patients; 0.16 +/- 0.1 microg/L; mean +/- standard error of the mean) versus nonenhancing scans (n = 8 patients; 0.069 +/- 0.04 microg/L). Primary brain tumors (n = 8 patients; 0.12 +/- 0.08) or central nervous system metastases also presented with elevated serum S100beta levels (n = 27 patients; 0.14 +/- 0.34). Tumor volume was correlated with serum S100beta levels only in patients with vestibular schwannoma (n = 6 patients; 0.13 +/- 0.10 microg/L) but not in patients with other brain lesions. Conclusions S100beta was correlated directly with the extent and temporal sequence of hyperosmotic BBBD, further suggesting that S100beta is a marker of BBB function. Elevated S100beta levels may indicate the presence of radiologically detectable BBB leakage. Larger prospective studies may better determine the true specificity of S100beta as a marker for BBB function and as an early detection or follow-up marker of brain tumors.

Background: Brain metastases are a leading cause of mortality and morbidity in patients with malignancies. Infratentorial location has been considered a negative prognostic factor. Methods: This retrospective study evaluated patients with cerebellar metastasis. Statistical analysis assessed age, extracranial disease, performance status and treatment. Patients were categorized by Radiation Therapy Oncology Group recursive partitioning analysis (RPA). Treatment included surgery, stereotactic radiosurgery (SRS) and whole brain radiotherapy (WBRT) alone or in combination. Results: Of 93 patients, the median survival was 12.9 months for RPA class I, 11 months for class II and 8 months for class III. On multivariate analysis, RPA class was an important predictor for overall survival. However, SRS with WBRT or surgery with WBRT or a combination of SRS, surgery and WBRT, was more favorable than surgery or SRS alone within RPA class II patients. Conclusions: Survival of patients with cerebellar brain metastasis is comparable to that of patients with supratentorial brain metastasis using RPA classification. Aggressive multimodality therapy has a favorable impact on survival.

Calcifications associated with both benign and neoplastic intra-axial lesions of the central nervous system (CNS) are well recognized. Bony metaplasia in the CNS, where there is formation of mature trabecular bone, is a much more rare entity and has not been reported in the spinal cord. We present a case of bony metaplasia in the conus medullaris associated with a low grade astrocytoma. Radiological, pathological and clinical features of this unique case are discussed.

Summary: The increasing consideration being given to the assessment of patients' quality of life (QOL) in contemporary neurosurgical clinical studies can be attributed to several factors, including technologic advances with escalating costs, the lack of a clear benefit in terms of length of survival (a traditional outcome measure) in several recent clinical trials of different treatment modalities, and the obvious need to rationalize the practice of neurosurgery by adopting an evidence-based approach. The current emphasis on patients' subjective experiences, satisfaction, and preferences as the goal of health care delivery also warranted development and psychometric validation of QOL instruments to assess these experiences and preferences. Our review shows that QOL research currently progressing in neurosurgery is wide ranging, although at a different pace in the subspecialties, with more utilization of disease-specific instruments in neuro-oncology than in the other subspecialties. The prospects are therefore encouraging for improving the quality of health care in neurosurgery, the ultimate goal of outcomes measurement.

Conventional shunting of isolated fourth ventricle is notorious for leading to frequent and severe complications. We present four patients with isolated fourth ventricle who have been treated with open posterior fossa surgery together with either outlet fenestration alone or outlet fenestration and a fourth ventricle-spinal subarachnoid space (SSS) shunt. A survey of the relevant literature did not yield any other case reports of fourth ventricle shunting to the SSS under such circumstances. This paper discusses the reasons for choosing this mode of treatment. The main advantage of this technique is that the catheter is inserted along the anatomical long axis of the fourth ventricle. This positioning lessens the possibility of irritating or penetrating the brain stem. Moreover, as a more physiological solution, the shunt does not require a valve system. Because of these advantages, internal fourth ventricle-SSS shunting is proposed as a valid alternative to the "classic" fourth ventriculo-peritoneal shunt.

The goal of this article was to evaluate the surgical technique and complications in 529 consecutive cases of the sellar area defects operated on through the one-nostril transsphenoidal approach over the last 10 years. There were 305 (58%) male patients and 224 (42%) female patients, aged from 14 to 90 years (mean 48 years). The patient is placed supine and the surgeon sits behind the patient's head. The microscope is placed above the head perpendicular to the C-arm of the x-ray intensifier. The speculum is introduced through the right nostril directly to the sphenoid rostrum. The nasal mucosa is coagulated at the septal insertion on the sphenoid rostrum, and the septum is pushed aside as a single mucoperichondral flap. The 2 mucosae are dissected on both sides of the sphenoid sinus and pushed aside by the tips of the speculum. Until the opening of the sphenoid sinus, the approach takes an average of 5 minutes. The duration of whole surgery was 35 to 125 minutes (mean 65 minutes). The 529 cases included 461 pituitary adenomas (including 43 reoperations), and 68 cases of other sellar defects. Eighteen different complications were analyzed and compared with a recent American National Survey. Our technique is compared with other approaches and positions. The role of an endoscope and navigation is evaluated. The one-nostril transsphenoidal approach is simpler, safer, and less time consuming than other types of transsphenoidal approaches.

Introduction: The American Association of Neurology issued guidelines discouraging the prophylactic use of anti-epilepsy drugs (AEDs) in patients with brain tumors. We surveyed neurosurgeons to evaluate practice patterns with regard to using AEDs in neurosurgical patients with brain tumors. Methods: The survey consisted of 18 questions. Two group email blasts containing an internet link to the survey were sent to members of the American Association of Neurological Surgeons with email addresses. Uni- and multi-variate analysis of the responses was performed using t-test, Fisher’s exact test, or chi-squared test, where appropriate. Results: The response rate was 15.5% (386/2491). The majority of respondents (270/386; 70.0%) had more than 5 years of experience in neurosurgery. Most respondents described their practices as general (224/379; 59.1%); about one-third were members of the Joint Section on Tumors (136/381; 35.7%). More than 70% of respondents reported routine use of AED prophylaxis for patients with intra-axial gliomas or brain metastases. AED prophylaxis was also routinely used for extra-axial benign tumors or stereotactic biopsies by 53.8% and 21.4%, respectively. On multivariate analysis, the number of years in practice of ABNS certified neurosurgeons was the strongest predictor for the use of AED prophylaxis. Conclusions: Routine use of AED prophylaxis in patients with brain tumors undergoing neurosurgical procedures remains the prevailing practice pattern among members of the AANS. Additional larger prospective studies with appropriate patient stratification culminating in development of neurosurgical guidelines on AED prophylaxis in brain tumor patients is warranted.

Hydrocephalus may become a major complicating factor in patients with suprasellar tumors. The differential diagnosis of suprasellar tumors that may potentially cause hydrocephalus is replete with various pathologies. Some tumors are more frequently associated with hydrocephalus (e.g., craniopharyngioma, optic pathway glioma), while others only occasionally cause it (e.g., germ cell tumor, pituitary adenoma, epidermoid cyst, and metastases). As hydrocephalus due to suprasellar tumors is primarily a pediatric neurosurgical problem, this chapter will be dedicated mostly to the management of hydrocephalus in pediatric patients with craniopharyngiomas and optic pathways gliomas (OPG).

The methods of treating hydrocephalus underwent a dramatic evolution in the last few decades. The initial enthusiasm of the neurosurgical community after years of using shunts as the only treatment of all kinds of hydrocephalus faded despite the fact that dozens of studies have been conducted, and hundreds of significant and seemingly panacean solutions were proposed to improve shunt technology. The reality remains that the overall survival of a shunt and the complication rate have changed only slightly in the last 10–20 years. It seems natural that the alternatives to placement of hardware have been long looked for, and the advent of modern neuroendoscopy in the mid-1980s opened a new page in the history of the war against hydrocephalus, which eventually turned into a war against shunts as well. Endoscopic third ventriculostomies (ETV) have instantly become very popular. ETV is a relatively simple technique, establishes a “natural” pathway for CSF flow, and may help to avoid placement of and reliance upon hardware. ETV is generally considered a safe and effective alternative for patients with triventricular hydrocephalus.

Calcifications associated with both benign and neoplastic intra-axial lesions of the central nervous system (CNS) are well recognized. Bony metaplasia in the CNS, where there is formation of mature trabecular bone, is a much more rare entity and has not been reported in the spinal cord. We present a case of bony metaplasia in the conus medullaris associated with a low grade astrocytoma. Radiological, pathological and clinical features of this unique case are discussed.

Object. In this study the authors evaluate the safety, efficacy, and indications for endoscopic third ventriculostomy (ETV) in patients with a history of subarachnoid hemorrhage or intraventricular hemorrhage (IVH) and/or cerebrospinal fluid (CSF) infection. Methods. The charts of 101 patients from seven international medical centers were retrospectively reviewed; 46 patients had a history of hemorrhage, 42 had a history of CSF infection, and 13 had a history of both disorders. All patients experienced third ventricular hydrocephalus before endoscopy. The success rate for treatment in these three groups was 60.9, 64.3, and 23.1%, respectively. The follow-up period in successfully treated patients ranged from 0.6 to 10 years. Relatively minor complications were observed in 15 patients (14.9%), and there were no deaths. A higher rate of treatment failure was associated with three factors: classification in the combined infection/hemorrhage group, premature birth in the posthemorrhage group, and younger age in the postinfection group. A higher success rate was associated with a history of ventriculoperitoneal (VP) shunt placement before ETV in the posthemorrhage group, even among those who had been born prematurely, who were otherwise more prone to treatment failure. The 13 premature infants who had suffered an IVH and who had undergone VP shunt placement before ETV had a 100% success rate. The procedure was also successful in nine of 10 patients with primary aqueductal stenosis. Conclusions. Patients with obstructive hydrocephalus and a history of either hemorrhage or infection may be good candidates for ETV, with safety and success rates comparable with those in more general series of patients. Patients who have sustained both hemorrhage and infection are poor candidates for ETV, except in selected cases and as a treatment of last resort. In patients who have previously undergone shunt placement posthemorrhage, ETV is highly successful. It is also highly successful in patients with primary aqueductal stenosis, even in those with a history of hemorrhage or CSF infection.

Object: Accurate placement of ventricular catheters in children with small ventricles can be difficult. Too often, shunt catheters are misplaced with regard to optimal postion and trajectory. The objective of this study was to determine whether neuronavigation-guided free-hand placement of ventricular catheters is an effective adjunct for children with hydrocephalus and small ventricles. Methods: Nine children with hydrocephalus (ages 1–12 years) participated in this study. Four children were diagnosed as suffering from slit ventricle syndrome and 5 children had small to mildly dilated ventricles. Of the 9 shunted children, 6 underwent previous shunt placements, and 1 child previously underwent an endoscopic third ventriculostomy. In 8 children the primary procedure was insertion of ventricular catheters using a frameless neuronavigation system. In 1 child, the neuronavigation system was used after failure to insert the ventricular catheter using a standard technique. All children showed significant improvement of their symptoms and signs following the procedure and none of them required shunt revision during the follow up period (mean 8±5 months). Conclusion: The usage of a neuronavigation system is safe and may be beneficial for optimal postioning and trajectory of ventricular catheters in children with small ventricles or an abnormal ventricular anatomy.

Object: The goal of this study was to evaluate the safety, efficacy, and indications for repeat endoscopic third ventriculostomies (ETV). Methods and results: We reviewed the records of 20 patients who had undergone repeat ETV from 1987 to 1999. Their ages ranged from 8 months to 53 years (mean 17 years). The primary etiologies of hydrocephalus were: primary aqueductal stenosis (9 cases), tumor (5), Chiari malformation (2), prior infection (2), prior intraventricular hemorrhage (1), and blocked foramen of Monro (1 patient). The interval between the first and second ETVs ranged from 8 days to almost 6 years (mean 12.8 months). The intraoperative findings at repeat surgery were: occlusion of the primary orifice by scar (10 cases), virginal floor of the third ventricle (5 cases), pinhole ventriculostomy (3 cases), incompletely penetrated membrane (1 case), and blood clot occluding the orifice (1 case). The follow-up period ranged from 3 to 47 months (median 20 months). Repeat ETV was successful in 13 patients (65%). These patients did not require further shunting or other procedures during follow-up. Seven patients (35%) required placement of a shunt after repeat ETV. Several complications were observed in 1 patient (5%), including seizures, elevated ICP, bilateral pulmonary edema, and cardiac arrhythmia. This patient ultimately recovered fully; the ETV was successful, and the patient did not require a shunt. Conclusions: Based on the experience of this group of patients, repeat ETV is as effective and as safe as a primary ETV procedure, and should be attempted in selected patients.

Objective: This study evaluates the benefits of and indications for the orbito-cranial approach (OCA) in pediatric patients. Methods and results: The authors report their recent experience of using the OCA in 9 pediatric patients, 6 boys and 3 girls. The patients' ages ranged from 3 to 17 years (mean 9.6±5.16 years). Follow-up periods varied between 6 and 21 months (mean 12.6±5.9 months). Five patients were operated on for craniopharyngiomas, 2 for chiasmatic-hypothalamic astrocytomas, 1 for a recurrent hypothalamic gangliocytoma, and 1 for a hypothalamic hamartoma. In 7 cases a neuronavigation system (BrainLab) was utilized. The lesions were removed totally in 5 patients, near-totally in 1, subtotally in 2, and partially in 1 patient. An average increase of 30% in the area of vertical exposure significantly decreased the need for brain retraction. There was no mortality in this series. The only complications connected with the surgical approach were transient subgaleal cerebro-spinal fluid collections in 7 of 9 children and a subgaleal-peritoneal shunt placement in another patient. Conclusions: Our experience with this series of patients suggests that the OCA is as safe and beneficial in pediatric patients as it is in adults. It facilitates tumor removal by providing shorter access to and better exposure of the suprasellar area, thereby minimizing brain retraction.

Object: Endoscopic III ventriculostomy (ETV) is an effective and a rather safe treatment for noncommunicating hydrocephalus secondary to aqueductal stenosis and other obstructive pathologies. Though not devoid of risk, ETV is increasingly replacing shunt operations, and it prevents related complications, including overdrainage. Methods: We report a rare case of a large chronic subdural hematoma (ChSDH) after ETV in a patient with aqueductal stenosis. Three weeks after he was shunted elsewhere, he presented to us with clinical symptoms of intracranial hypotension and overdrainage. ETV was performed and the shunt removed uneventfully. On routine postoperative MRI a few weeks later, a large ChSDH was noted, the patient being totally asymptomatic. Since the ChSDH grew significantly, causing a mass effect on the follow-up MRI, it was finally drained. Large and increasing ChSDHs have previously been reported secondary to overdrainage after shunt placement, but not after ETV. Conclusions: We conclude that though rare, a ChSDH may evolve even after ETV, if there is a substantial decrease in previously elevated intracranial pressure.