Oculomotor nerve cavernous malformation: case report and operative video.

BACKGROUND: Cavernous malformations (CMs) are clusters of thin-walled sinusoidal vessels without well-defined walls. Though they can occur anywhere in the neuroaxis, cranial nerve (CN) CMs are rare. METHOD: We report a 47-year-old male with gradual CN III palsy. Initial imaging showed no significant findings, but a follow-up MRI revealed a growing lesion along CN III. Intraoperative findings confirmed a CN III CM. Diagnosing and treating CN III CM are complex. Radiological findings lack specificity, requiring consideration of various diagnoses for patients with isolated CN III palsy and abnormal radiological findings. CONCLUSION: Surgery is the gold standard, aiming for complete lesion removal while minimizing neurological complications.

Superior orbital fissure narrowing and tumor-associated pain in spheno-orbital meningiomas.

INTRODUCTION: Spheno-orbital meningiomas (SOMs) represent a distinct subtype of meningioma characterized by their unique multi-compartmental invasion pattern. Previous studies have investigated correlations between SOMs and visual manifestations. However, our comprehension of pain associated with SOMs remains limited. This study aims to provide insight into the pathophysiology underlying SOM-related pain through measurements of tumor volume and superior orbital fissure (SOF) narrowing. METHODS: This retrospective study included patients who underwent surgical resection of a SOM between 2000 and 2022. Preoperative CT and/or MRI scans were analyzed, and the tumor volume of each segment was measured. Bony 3D reconstructions were used to measure the area of the SOF, and SOF narrowing was calculated. RESULTS: The study cohort included 66 patients diagnosed with SOMs, among which 25.8% (n = 17) presented with pain. Postoperatively, 14/17 (82.4%) of patients reported pain improvement. There was no significant correlation between the total volume or the volume of tumor within each compartment and the presence of pain on presentation (p > 0.05). The median SOF narrowing was significantly different between patients presenting with and without tumor-associated pain with median of 11 mm2 (IQR 2.8-22.3) and 2 mm2 (IQR 0-6), respectively (p = 0.005). Using logistic regression, a significant correlation between the degree of SOF narrowing and the presence of SOM-associated pain on presentation was identified, with an aOR of 1.2 (95% CI 1.12-1.3, p = 0.02). CONCLUSION: While the exact cause of tumor-associated pain remains unclear, SOF narrowing seems to play a role in pain among SOM patients. Based on the radiological characteristics, SOF neurovascular decompression is recommended in SOM patients.

Surgical management of spontaneous middle cranial fossa defects: a systematic review and meta-analysis of available reconstructive techniques and materials.

Different materials and techniques have been proposed for surgical repair of spontaneous middle cranial fossa (MCF) defects. However, conclusive evidence supporting their selection and impact on clinical outcomes is lacking. The study aims to conduct a systematic review and meta-analysis on materials and techniques employed to repair MCF defects and evaluate complications and rates of recurrent cerebrospinal fluid (CSF) leaks. A PRISMA-guided systematic review and meta-analysis were performed using MESH terms and specific keywords including studies published before May 2022. Primary outcomes included recurrence of CSF leak and complication rates by type of reconstructive material and technique utilized. Meta-analyses of proportions were performed using random effects and confidence intervals for individual proportions were calculated using the Clopper-Pearson method. Twenty-nine studies were included (n = 471 cases). Materials employed for repair were categorized according to defect size: 65% of defects were of unknown size, 24% were small (< 1 cm), and 11% were large (≥ 1 cm). Rigid reconstruction (RR) was significantly favored over soft reconstruction (SR) for larger defects (94% of cases, p < 0.05). Complications and recurrent CSF leak rates of SR and RR techniques were comparable for defects of all sizes (p > 0.05). Complication rates reported for these procedures are low regardless of technique and material. RR was universally preferred for larger defects and analysis of complication and recurrence rates did not reveal differences regardless of defect size. While RR was more frequently reported in smaller defects, SR was used by several centers, particularly for smaller MCF floor defects.

Combination anti-CXCR4 and anti-PD-1 immunotherapy provides survival benefit in glioblastoma through immune cell modulation of tumor microenvironment.

BACKGROUND: Emerging evidence suggests that myeloid cells play a critical role in glioblastoma (GBM) immunosuppression. Disappointing results of recent checkpoint inhibitor trials suggest that combination immunotherapy with alternative agents could be fruitful in overcoming immunosuppression. Overexpression of chemokine receptor CXCR4 is associated with poor prognosis in GBM. We investigate the treatment effects of combination immunotherapy with anti-PD-1 and anti-CXCR4 in a murine glioma model. METHODS: C57BL/6 mice were implanted with GL261-Luc+ glioma cells and randomized into 4 arms: (1) control (2) anti-PD-1 (3) anti-CXCR4, and (4) anti-PD-1 and anti-CXCR4 therapy. Overall survival and median survival were assessed. Cell populations were assessed by flow cytometry. RESULTS: Combination therapy conferred a significant survival benefit compared to control and monotherapy arms. Mice that received combination therapy demonstrated immune memory and decreased populations of immunosuppressive tumor-infiltrating leukocytes, such as monocytic myeloid-derived suppressor cells and microglia within the brain. Furthermore, combination therapy improved CD4+/CD8+ ratios in the brain as well as contributed to increased levels of pro-inflammatory cytokines. CONCLUSIONS: Anti-CXCR4 and anti-PD-1 combination immunotherapy modulates tumor-infiltrating populations of the glioma microenvironment. Targeting myeloid cells with anti-CXCR4 facilitates anti-PD-1 to promote an antitumor immune response and improved survival rates.

Hemorrhage Risk of Brain Arteriovenous Malformations During Pregnancy and Puerperium in a North American Cohort.

BACKGROUND AND PURPOSE: Conclusions reached in existing literature about risk of arteriovenous malformation (AVM) hemorrhage during pregnancy are controversial. This study compares the risk of hemorrhage in pregnant and nonpregnant female patients with AVM in a North American cohort. METHODS: We retrospectively reviewed female patients with AVM evaluated from 1990 to 2015. Exposure period for pregnancy and puerperium was calculated as 40 and 6 weeks, respectively, for each full-term pregnancy and 6 weeks for each abortion. Hemorrhage events and patient-years were calculated during an exposure period (pregnancy and puerperium), and a nonexposure period defined as either the interval from birth until AVM obliteration or until last follow-up after subtracting exposure period. Poisson rate ratio test was used to compare rate of hemorrhage between exposure and nonexposure periods. RESULTS: For 270 female patients with AVM, mean age was 35.0±19.6 years, and race distribution was white (n=165, 61.1%), black (n=59, 21.9%), Hispanic (n=9, 3.3%), Asian (n=6, 2.2%), and other (n=31, 11.5%). From 191 total pregnancies occurring before AVM obliteration, there were 175 (91.6%) term deliveries and 16 (8.4%) abortions. Overall annual hemorrhage rate for 149 total hemorrhages during an average of 11 097 patient-years was 1.34%. There were 140 hemorrhages in nonexposed women and 9 hemorrhages in pregnant women, translating to an annual hemorrhage rate of 1.3% in nonpregnant women versus 5.7% in pregnant women (P<0.001). Identical analysis for reproductive age patients (15-50) demonstrated a rate of 1.3% versus 7.0% (P<0.001). CONCLUSIONS: Our results conflict with those from a recent study describing no increased rate of rupture during pregnancy. This difference may reflect unique population attributes influencing brain AVM hemorrhage during pregnancy.

BRAF-V600 mutational status affects recurrence patterns of melanoma brain metastasis.

Brain metastasis is common and carries a poor prognosis in melanoma. A single institution, retrospective cohort of 225 melanoma patients was analyzed to determine if BRAF-V600 mutational status was associated with brain metastasis. Eighty-three of the 225 patients (37%) had BRAF-V600 mutations. At initial diagnosis, BRAF-V600 mutations were associated with younger age (p ≤ 0.001), higher proportion of females (p = 0.0037), higher AJCC stage (p = 0.030), regional lymph node involvement (p = 0.047), and family history of cancer (p = 0.044). Compared to BRAF-WT, BRAF-V600 patients had an increased risk of brain metastasis in multivariate analysis (OR = 2.24; 95% CL = 1.10-4.58; p = 0.027). However, BRAF-V600 patients treated with a selective BRAF inhibitor (BRAFi) had a similar risk of brain metastasis compared to BRAF-WT patients (OR = 1.00; 95% CL = 0.37-2.65; p = 0.98). Moreover, treatment with BRAFi significantly prolonged the time from initial diagnosis to brain metastasis diagnosis (HR = 0.30; 95% CL = 0.11-0.79; p = 0.015). Compared to other tissues, the brain was the most frequent site of metastasis in BRAF-V600 patients without BRAFi (42% ± 7%). The frequency of brain metastasis was lower in BRAF-WT and BRAF-V600 patients with BRAFi (25% ± 4% and 25% ± 8%, respectively). The proportion of patients with brain metastasis as the only site was 40%, 60%, and 0% in the BRAF-WT, BRAF-V600 without BRAFi, and BRAF-V600 with BRAFi groups, respectively. This study provides evidence on the clinical importance of BRAF-V600 mutations and BRAF inhibition in the progression to melanoma brain metastasis.

The Potential of Cellular- and Viral-Based Immunotherapies for Malignant Glioma-Dendritic Cell Vaccines, Adoptive Cell Transfer, and Oncolytic Viruses.

PURPOSE OF REVIEW: Malignant gliomas, including glioblastoma and anaplastic astrocytoma, are the most frequent primary brain tumors and present with many treatment challenges. In this review, we discuss the potential of cellular- and viral-based immunotherapies in the treatment of malignant glioma, specifically focusing on dendritic cell vaccines, adoptive cell therapy, and oncolytic viruses. RECENT FINDINGS: Diverse cellular- and viral-based strategies have been engineered and optimized to generate either a specific or broad antitumor immune response in malignant glioma. Due to their successes in the preclinical arena, many of these therapies have undergone phase I and II clinical testing. These early clinical trials have demonstrated the feasibility, safety, and efficacy of these immunotherapies. Dendritic cell vaccines, adoptive cell transfer, and oncolytic viruses may have a potential role in the treatment of malignant glioma. However, these modalities must be investigated in well-designed phase III trials to prove their efficacy.

Intraoperative imaging techniques for glioma surgery.

Gliomas are CNS neoplasms that infiltrate the surrounding brain parenchyma, complicating their treatment. Tools that increase extent of resection while preventing neurological deficit are essential to improve prognosis of patients diagnosed with gliomas. Tools such as intraoperative MRI, ultrasound and fluorescence-guided microsurgery have been used in the surgical resection of CNS gliomas with the goal of maximizing extent of resection to improve patient outcomes. In addition, emerging experimental techniques, for example, optical coherence tomography and Raman spectroscopy are promising techniques which could 1 day add to the increasing armamentarium used in the surgical resection of CNS gliomas. Here, we present the potential advantages and limitations of these imaging techniques for the purposes of identifying gliomas in the operating room.

Instrumented fusion for spinal deformity after laminectomy or laminoplasty for resection of intramedullary spinal cord tumors in pediatric patients.

OBJECTIVE Spinal deformity has become a well-recognized complication of intramedullary spinal cord tumor (IMSCT) resection. In particular, laminectomy can result in biomechanical instability caused by loss of the posterior tension band. Therefore, laminoplasty has been proposed as an alternative to laminectomy. Here, the authors describe the largest current series of pediatric patients who have undergone laminoplasty for IMSCT resection and investigate the need for surgical fusion after both laminectomy and laminoplasty. METHODS The medical records of pediatric patients who underwent resection of an IMSCT at a single institution between November 2003 and May 2014 were reviewed retrospectively. Demographic, clinical, radiological, surgical, histopathological, and follow-up data were collected. RESULTS Sixty-six consecutive patients underwent resection of an IMSCT during the study period. Forty-three (65%) patients were male. The patients had a median age of 12.9 years (interquartile range [IQR] 7.2-16.5 years) at the time of surgery. Patients typically presented with a tumor that involved the cervical and/or thoracic spine. Nineteen (29%) patients underwent laminectomy, and 47 (71%) patients underwent laminoplasty. Patients in each cohort had a similar rate of postoperative deformity. Overall, 10 (15%) patients required instrumented spinal fusion for spinal deformity. Four patients required revision of the primary fusion. CONCLUSIONS These findings show that among pediatric patients with an IMSCT, postoperative surgical fusion rates remain high, even after laminoplasty. Known risk factors, such as the age of the patient, location of the tumor, and the number of involved levels, might play a larger role than replacement of the laminae in determining the rate of surgical fusion after IMSCT resection.

Influence of insurance status on survival of adults with glioblastoma multiforme: A population-based study.

BACKGROUND: To the authors' knowledge, the impact of insurance status on the survival time of patients with glioblastoma multiforme (GBM) has not been fully understood. The objective of the current study was to clarify the association between insurance status and survival of patients with GBM by analyzing population-based data. METHODS: The authors performed a cohort study using data from the Surveillance, Epidemiology, and End Results program. They included adult patients (aged ≥18 years) with GBM as their primary diagnosis from the years 2007 to 2012. Patients without information regarding insurance status were excluded. A survival analysis between insurance status and GBM-related death was performed using an accelerated failure time model. Demographic and clinical variables were included to adjust for confounding effects. RESULTS: Among the 13,665 adult patients in the study cohort, 558 (4.1%) were uninsured, 1516 (11.1%) had Medicaid coverage, and 11,591 (84.8%) had non-Medicaid insurance. Compared with patients who were uninsured, insured patients were more likely to be older, female, white, married, and with a smaller tumor size at diagnosis. Accelerated failure time analysis demonstrated that older age (hazard ratio [HR], 1.04; P<.001), male sex (HR, 1.08; P<.001), large tumor size at the time of diagnosis (HR, 1.26; P<.001), uninsured status (HR, 1.14; P =.018), and Medicaid insurance (HR, 1.10; P =.006) were independent risk factors for shorter survival among patients with GBM, whereas radiotherapy (HR, 0.40; P<.001) and married status (HR, 0.86; P<.001) indicated a better outcome. The authors discovered an overall yearly progressive improvement in survival in patients with non-Medicaid insurance who were diagnosed from 2007 through 2011 (P =.015), but not in uninsured or Medicaid-insured patients. CONCLUSIONS: Variations existed in insurance status within the GBM population. Uninsured status and Medicaid insurance suggested shorter survival compared with non-Medicaid insurance among a population of patients with GBM. Cancer 2016;122:3157-65. © 2016 American Cancer Society.

Chiari Type 1 Deformity in Children: Pathogenetic, Clinical, Neuroimaging, and Management Aspects.

Our understanding of cerebellar tonsillar herniation evolved over time and nowadays various pathomechanisms have been proposed. Causes of tonsillar herniation share a discrepancy between content (fore- and hindbrain) and container (supratentorial cranial vault, posterior fossa), may be associated with abnormalities of the craniocervical junction, and may have a developmental or acquired nature. In tonsillar herniation, the hindbrain is not malformed but deformed. Accordingly, "Chiari type 1 deformity," not "Chiari type 1 malformation" is the correct term to characterize primary tonsillar herniation. Chiari type 1 deformity is commonly seen in pediatric neurology, neuroradiology, and neurosurgery and may have various clinical presentations depending on patient age. In addition, Chiari type 1 deformity is increasingly found by neuroimaging studies as an incidental finding in asymptomatic children. An accurate and reliable selection of patients based on clinical and neuroimaging findings is paramount for the success of neurosurgical treatment. Future studies are needed to provide selection criteria with a higher sensitivity and specificity.

Hemorrhage Risk in Pediatric Patients with Multiple Intracranial Arteriovenous Malformations.

BACKGROUND/AIMS: This study aims to characterize the clinical features, treatment strategies, and annual hemorrhage incidence rate of pediatric patients with multiple arteriovenous malformations (MAVM). METHODS: The PubMed and EMBASE databases and the arteriovenous malformations (AVM) database at the Johns Hopkins Hospital were searched for reports of pediatric patients (under 21 years of age) with MAVM. Data related to demographics, clinical features, management, and treatment outcomes were analyzed using descriptive statistics. Twenty-four pediatric patients met the inclusion criteria. RESULTS: The annual hemorrhage incidence rate was 2.1%. The most common presenting features were neurological deficit (38%) and hemorrhage (21%). Treatment with embolization has become the most frequently used modality. In patients undergoing staged treatment of MAVM, hemorrhage of an untreated nidus (n = 1), visualization of a new nidus (n = 2), or disappearance of a draining vein (n = 1) occurred. CONCLUSION: The annual hemorrhage incidence rate for pediatric patients with MAVM approaches the upper range of previously reported hemorrhage rates for solitary AVM. A staged approach to treating MAVM requires close follow-up as changes to the remaining nidi may occur during the latency period. Limitations of this study include its small sample size and reporting bias.

Regulation of brain tumor dispersal by NKCC1 through a novel role in focal adhesion regulation.

Glioblastoma (GB) is a highly invasive and lethal brain tumor due to its universal recurrence. Although it has been suggested that the electroneutral Na(+)-K(+)-Cl(-) cotransporter 1 (NKCC1) can play a role in glioma cell migration, the precise mechanism by which this ion transporter contributes to GB aggressiveness remains poorly understood. Here, we focused on the role of NKCC1 in the invasion of human primary glioma cells in vitro and in vivo. NKCC1 expression levels were significantly higher in GB and anaplastic astrocytoma tissues than in grade II glioma and normal cortex. Pharmacological inhibition and shRNA-mediated knockdown of NKCC1 expression led to decreased cell migration and invasion in vitro and in vivo. Surprisingly, knockdown of NKCC1 in glioma cells resulted in the formation of significantly larger focal adhesions and cell traction forces that were approximately 40% lower than control cells. Epidermal growth factor (EGF), which promotes migration of glioma cells, increased the phosphorylation of NKCC1 through a PI3K-dependant mechanism. This finding is potentially related to WNK kinases. Taken together, our findings suggest that NKCC1 modulates migration of glioma cells by two distinct mechanisms: (1) through the regulation of focal adhesion dynamics and cell contractility and (2) through regulation of cell volume through ion transport. Due to the ubiquitous expression of NKCC1 in mammalian tissues, its regulation by WNK kinases may serve as new therapeutic targets for GB aggressiveness and can be exploited by other highly invasive neoplasms.

Impact of Latency Variations on the Predictive Value of Facial Nerve Proximal-to-Distal Amplitude Ratio during Vestibular Schwannoma Surgery.

Introduction This study highlights the relation between compound muscle action potential (CMAP) latency variations and the predictive value of facial nerve (FN) proximal-to-distal (P/D) amplitude ratio measured at the end of vestibular schwannoma resection. Methods Forty-eight patients underwent FN stimulation at the brainstem (proximal) and internal acoustic meatus (distal) using a current intensity of 2 mA. The proximal latency and the P/D amplitude ratio were assessed. House-Brackmann grades I & II indicated good FN function, and grades III to VI were considered fair/poor function. A P/D amplitude ratio > 0.6 was used as a cutoff to indicate a good FN function, while a ratio of ≤ 0.6 indicated a fair/poor FN function. Results The P/D amplitude ratio was measured for all patients, and the calculated sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) were 85.2, 85.7, 88.5, and 81.8%, respectively. The CMAPs from the mentalis muscle were then classified based on their proximal latency into group I (< 6 ms), group II (6-8 ms), and group III (> 8 ms). The SE, SP, PPV, and NPV became 90.5, 90.9, 95, and 83.3%, respectively, in group II. In group I, SE and NPV increased, whereas SP and PPV decreased. While in group III, SP and PPV increased, whereas SE and NPV decreased. Conclusion At a latency between 6 and 8 ms, the P/D amplitude ratio was predictive of outcomes with high SE and SP. When latency was < 6 ms or > 8 ms, the same predictive ability was not observed. Knowing the strengths and limitations is important for understanding the predictive value of the P/D amplitude ratio.

An Artificial Neural Network Model for Predicting Postoperative Facial Nerve Outcomes After Vestibular Schwannoma Surgery.

BACKGROUND AND OBJECTIVES: The emergence of machine learning models has significantly improved the accuracy of surgical outcome predictions. This study aims to develop and validate an artificial neural network (ANN) model for predicting facial nerve (FN) outcomes after vestibular schwannoma (VS) surgery using the proximal-to-distal amplitude ratio (P/D) along with clinical variables. METHODS: This retrospective study included 71 patients who underwent VS resection between 2018 and 2022. At the end of surgery, the FN was stimulated at the brainstem (proximal) and internal acoustic meatus (distal) and the P/D was calculated. Postoperative FN function was assessed using the House-Brackmann grading system at discharge (short-term) and after 9-12 months (long-term). House-Brackmann grades I-II were considered good outcome, whereas grades III-VI were considered fair/poor. An ANN model was constructed, and the performance of the model was evaluated using the area under the ROC curve for internal validation and accuracy, sensitivity, specificity, and positive and negative predictive values for external validation. RESULTS: The short-term FN outcome was grades I-II in 57.7% and grades III-VI in 42.3% of patients. Initially, a model using P/D had an area under the curve of 0.906 (internal validation) and an accuracy of 89.1% (95% CI: 68.3%-98.8%) (external validation) for predicting good vs fair/poor short-term FN outcomes. The model was then refined to include only muscles with a P/D with a proximal latency between 6 and 8 ms. This improved the accuracy to 100% (95% CI: 79%-100%). Integrating clinical variables (patient's age, tumor size, and preoperative HB grade) in addition to P/D into the model did not significantly improve the predative value. A model was then created to predict the long-term FN outcome using P/D with latencies between 6 and 8 ms and had an accuracy of 90.9% (95% CI: 58.7%-99.8%). CONCLUSION: ANN models incorporating P/D can be a valuable tool for predicting FN outcomes after VS surgery. Refining the model to include P/D with latencies between 6 and 8 ms further improves the model's prediction. A user-friendly interface is provided to facilitate the implementation of this model.

Comparison of Resection Assisting Devices in the Process of Collecting Brain Tumor Tissue for Basic Research: Microdebrider Versus Ultrasonic Aspirator.

INTRODUCTION: Brain tumors display significant inter and intratumoral heterogeneity, impacting disease progression and outcomes. Preserving surgically resected tissue is vital for ensuring accurate research results to enhance understanding of tumor pathophysiology. This study evaluates tissue integrity and viability of tissue resected using 2 surgical devices for tumor resection: a mechanical microdebrider (MD) and an ultrasonic aspirator (UA). METHODS: Tumor samples were obtained from patients undergoing surgical resection of primary and secondary intracranial tumors. Cell viability was assessed, and histopathological analysis of Hematoxylin and Eosin -stained tissues was performed. Adherent monolayer and neurospheres cell cultures were established from paired samples. RNA isolation and quantitative polymerase chain reaction of housekeeping genes were conducted to compare genetic integrity. RESULTS: The cellular viability was comparable between samples obtained using both the MD and the UA, with a mean viability of 75.2% ± 15.6 and 70.7% ± 16.8, respectively (P = 0.318). Histopathological evaluation indicated no discernible differences in cellular integrity between the devices. Cell culture success rates and growth characteristics were similar for both devices. RNA concentration and integrity were well-maintained in both MD and UA samples, with no significant differences (P = 0.855). Quantitative polymerase chain reaction analysis of housekeeping genes showed consistent results across matched tissues from both devices and different tumor pathologies. CONCLUSIONS: Surgical handheld devices provide valuable, high-quality tissue samples for research. Surgeon preference, tumor pathology, and anatomical location dictate device choice. Both MD and UA devices are reliable for obtaining quality tissue specimens, facilitating translational neuro-oncology research.

The vectorial technique: a novel neuronavigation-based tool to measure angles of exposure during skull base dissections.

The angle of exposure (AnE) represents a metric that is particularly useful for analyzing circular bony structures during skull base dissections. The authors aimed to develop and validate a neuronavigation-based method to measure the AnE. A formula based on vectorial geometry and the coordinates of three points collected with a neuronavigation system was developed to measure the AnE. The method was validated using a plexiglass phantom head. To demonstrate its applicability, the authors measured the AnE in 6 cadaveric specimens after exposure of the hypoglossal canal using a far-medial approach (FMA) and a far-lateral transtubercular approach (FLTA) and in 6 different specimens after exposure of the jugular foramen using an FLTA and a retrosigmoid approach (RSA). The mean angles measured at 45°, 90°, and 180° using a goniometer during the validation test were 44.8° ± 1.1°, 90.8° ± 1.2°, and 179.7° ± 0.8° using the novel formula (p > 0.05). In the first illustrative application, the mean AnEs for the FMA and FLTA were 129° ± 0.9° and 243° ± 1.9°, respectively. In the second scenario, the mean AnEs were 192° ± 1.3° for the FTLA and 143° ± 2.1° for the RSA. The neuronavigation-based technique described is a highly accurate method to measure the AnE.

Volumetric Analysis of Spheno-Orbital Meningiomas: Prognostic Correlation and a Compartmentalized Approach.

BACKGROUND AND OBJECTIVES: Spheno-orbital meningiomas arise from the arachnoid villi cap cells at the sphenoid ridge and have the ability to spread through soft tissue extension and cranial bone invasion. Owing to their orbital hyperostosis and intraorbital soft tissue extension, they commonly present with ophthalmologic manifestations. This study aims to investigate the correlation between tumor volume with the presenting symptoms and postoperative outcomes. METHODS: This retrospective study analyzed patients who underwent surgical resection of spheno-orbital meningiomas. Tumor volumes in different compartments were measured using preoperative and postoperative imaging. Linear and logistic regression analyses were used to identify correlations between tumor volumes and presenting symptoms preoperatively and postoperative outcomes. RESULTS: Sixty-six patients were included in this study, of whom 86.4% had proptosis, 80.3% had decreased visual acuity (VA), 30.3% had visual field defects, and 13.6% had periorbital edema. Preoperatively, proptosis linearly correlated with intraosseous tumor volume (coefficient = 0.6, P < .001), while the decrease in baseline VA correlated with the intraorbital tumor volume (coefficient = 0.3, P = .01). The odds of periorbital edema were found to increase with an increase in intraosseous tumor volume with an adjusted odds ratio of 1.4 (95% CI, 1.1-1.7, P = .003), while the odds of visual field defects were found to increase with an increase in intraorbital tumor volume with an adjusted odds ratio of 2.7 (95% CI, 1.3-5.6, P = .01). Postoperatively, the volume of intraosseous tumor resected linearly correlated with the improvement in proptosis (coefficient = 0.7, P < .001), while the volume of intraorbital tumor resected linearly correlated with improvement in VA (coefficient = 0.5, P < .001) and with a larger effect size in patients presenting with moderate-to-severe decrease in VA preoperatively (coefficient = 0.8). CONCLUSION: Underscoring the importance of each tumor compartment relative to the patient's symptomatology serves as a valuable guide in implementing a compartmentalized resection approach tailored to the surgical objectives.

Pediatric infectious aneurysms: individual patient pooled analysis on presentation, management and outcomes.

BACKGROUND: Infectious intracranial aneurysms (IIAs) are a rare sequel of systemic infection and occur most commonly in patients with infective endocarditis (IE). Despite the increasing use of non-invasive screening angiography in patients with IE, the incidence remains low, yielding limited data on the management of IIAs in pediatric populations. We performed a pooled analysis of all published series of pediatric patients with IIAs to study the disease landscape including presentation, management, and outcomes. METHODS: Data included in this study were pooled from published literature on IIAs between 1960 and 2023. Abstracts were selected for full review to include only manuscripts reporting at least one case of pediatric IIA (age 0-18 years). RESULTS: A total of 145 pediatric patients with 178 IIAs were included. Patients presented with rupture in 68% of cases, of which 36% had intraparenchymal hemorrhage and 39% had subarachnoid hemorrhage. Using multivariate logistic regression, independent predictors of rupture were posterior location (aOR 10, P=0.041) and history of IE (aOR 7.2, P=0.001). Primary medical management was successful in 82% of cases with unruptured aneurysms while, in those with ruptured IIAs, medical management was successful in 26% of cases. The 90-day mortality rate was 28%. Using multivariate logistic regression, ruptured IIAs (aOR 5.4, P<0.01) and failure of medical management (aOR 11.1, P<0.05) were independent predictors of 90-day mortality. CONCLUSION: Pediatric IIAs remain a rare complication of systemic or localized CNS infection in the pediatric population. Medical management of unruptured aneurysms is highly successful, while ruptured aneurysms have a remarkably high rate of failure of medical management and should be treated by early surgical or endovascular intervention when feasible.

Histopathological correlates with survival in reoperated glioblastomas.

The addition of concomitant and adjuvant chemotherapy to radiation therapy after surgical resection has increased significantly the survival of patients with glioblastoma (GB). In conjunction, there has been an increasing fraction of patients who present with new enlarged areas of contrast enhancement and edema on post-treatment imaging that improve without further treatment. It remains to be established how this phenomenon, commonly termed pseudoprogression, can be distinguished from true tumor recurrence defined as the histological presence of active high-grade tumor, as well as its prognostic significance. Data for over 500 patients undergoing surgery for recurrent GB were reviewed. Pathological specimens were categorized as those that contained active high-grade glioma in any amount, and those that did not. Patient survival was compared between these two groups, and independent associations were assessed using Cox proportionate hazards regression analysis. 59 patients met the study criteria including complete pathological and follow-up data. Mean age was 53 ± 11 years. Median survival from suspected recurrence and initial diagnosis were 8 [5-14] and 20 [12-30] months. Seventeen patients (29 %) had no evidence of active high-grade tumor and 42 (71 %) had at least focal active high-grade glioma. Pathologic pseudoprogression at re-operation (p = 0.03) and gross total resection (p = 0.01) were independently associated with survival. The histopathological features defined here and used to assess the tumor at reoperation were independently associated with survival. These findings may be important in designing treatment strategies and clinical trial endpoints for patients with GB.