Hearing preservation and quality of life in small to medium sized vestibular schwannomas after a wait and scan approach or stereotactic radiosurgery: a systematic review and meta-analysis.

BACKGROUND: The management of vestibular schwannomas (VS) encompasses a choice between conservative "wait-and-scan" (WAS) approach, stereotactic radiosurgery (SRS) or open microsurgical resection. Currently, there is no consensus on the optimal management approach for small to medium sized VS. This study aims to compared outcomes related to hearing in patients with small and medium sized VS who underwent initial treatment with WAS versus SRS. METHODS: A systematic review of the available literature was conducted using PubMed/MEDLINE, Embase, and Cochrane up December 08, 2023. Meta-analysis was performed using a random-effect model to calculate mean difference (MD) and relative risk (RR). A leave-one-out analysis was conducted. The risk of bias was assessed via the Risk of Bias in Non-randomized Studies-Interventions (ROBINS-I) and Cochrane Risk of Bias assessment tool (RoB-2). Ultimately, the certainty of evidence was evaluated using the GRADE assessment. The primary outcomes were serviceable hearing, and pure-tone average (PTA). The secondary outcome was the Penn Acoustic Neuroma Quality of Life Scale (PANQOL) total score. RESULTS: Nine studies were eligible for inclusion, comprising a total of 1,275 patients. Among these, 674 (52.86%) underwent WAS, while 601 patients (47.14%) received SRS. Follow-up duration ranged from two to eight years. The meta-analysis indicated that WAS had a better outcome for serviceable hearing (0.47; 95% CI: 0.32 - 0.68; p < 0.001), as well as for postoperative functional measures including PTA score (MD 13.48; 95% CI 3.83 - 23.13; p < 0.01), and PANQOL total score (MD 3.83; 95% CI 0.42 - 7.25; p = 0.03). The overall certainty of evidence ranged from "very low" to "moderate". CONCLUSIONS: Treating small to medium sized VS with WAS increases the likelihood of preserving serviceable hearing and optimized PANQOL overall postoperative score compared to SRS. Nevertheless, the limited availability of literature and the methodological weakness observed in existing studies outline the need for higher-quality studies.

Traumatic middle meningeal arteriovenous fistulas (MMAVFs): an exploratory systematic review.

This study aims to systematically review case reports and case series in order to compare the postoperative course of conservative, endovascular and surgical treatments for traumatic dural arteriovenous fistulas predominantly supplied by the middle meningeal artery (MMAVFs), which usually occur following head trauma or iatrogenic causes. We conducted a comprehensive search of PubMed, Embase, Scopus, Web of Science, and Google Scholar until June 23rd, 2024. Three cohorts were defined based on the treatment modality employed. The primary outcomes were the rates of overall obliteration and postoperative complications, with all-cause mortlality considered as secondary outcome. A total of 61 studies encompassing 78 pooled MMAVFs were included in the qualitative analysis. The predominant demographic consisted of males (53.9%) with a median age of 50.5 (IQR: 33.5-67.5) years. The main etiologies for fistula formation were head trauma (75.6%), cranial neurosurgical procedures (11.5%) and endovascular embolization (8.97%). Venous drainage patterns were categorized as follows based on anatomical confluence: Class I (16.7%), II (14.1%), III (12.8%), IV (14.1%), V (7.7%), and VI (3.9%). Regarding treatment efficacy, the overall obliteration rate was 89.74%, achieved through endovascular (95.83%), surgical (64.29%) or conservative (93.75%) approaches. In terms of safety, the overall postoperative complication rate was 6.49% with an all-cause mortality rate of 8.97%, predominantly observed in the surgical group (35.71%). Our systematic review highlights the challenging management of traumatic MMAVFs, frequently associated with head injuries. Endovascular therapy has emerged as the predominant treatment modality, demonstrating markedly higher rates of fistula obliteration, reduced all-cause mortality, and fewer postoperative complications.

The Impact of Perilesional Heatsink Structures on Ablation Volumes in Laser Interstitial Thermal Therapy for Brain Metastases.

BACKGROUND AND OBJECTIVES: Laser interstitial thermal therapy (LITT) has demonstrated promise in surgical neuro-oncology because of its effectiveness in delivering precise thermal energy to lesions. The extent of ablation (EOA) is a prognostic factor in improving patient outcomes but is often affected by perilesional heatsink structures, which can lead to asymmetric ablations. The purpose of this study was to quantitatively evaluate the impact of various perilesional heatsink structures on the EOA in LITT for brain metastases. METHODS: Twenty-seven procedures for 22 unique patients with brain metastases fit the inclusion criteria. Intracranial heatsink structures were identified: sulci, meninges, cerebrospinal fluid (CSF) spaces, and vasculature. Asymmetric ablation was determined by measuring 3 pairs of orthogonal distances from the proximal, midpoint, and distal locations along the laser catheter to the farthest edge of the ablation zone bilaterally. Distances from the same points on the laser catheter to the nearest heatsink were also recorded. The Heatsink Effect Index was created to serve as a proxy for asymmetric ablation. Pearson correlations, t -tests, and analysis of variance were the statistical analyses performed. RESULTS: From the midpoint of the catheter, the 27 heatsinks were meninges (40.7%), sulci (22.2%), vasculature (22.2%), and CSF spaces (14.8%). Across all points along the catheter track, there was a significant generalized heatsink effect on asymmetric ablations ( P < .0001). There was a negative correlation observed between asymmetric ablations and EOA from the midpoint of the laser catheter (r = -0.445, P = .020). Compared with sulci, CSF spaces trended toward a greater effect on asymmetric ablation volumes ( P = .069). CONCLUSION: This novel quantitative analysis shows that perilesional heatsinks contribute to asymmetric ablations. CSF spaces trended toward higher degrees of asymmetric ablations. Importantly, neurosurgeons may anticipate asymmetric ablations preoperatively if heatsinks are located within 13.3 mm of the laser probe midpoint. These preliminary results may guide surgical decision-making in LITT for metastatic brain lesions.

Structure-sparing resection for the management of cervical chordomas: a retrospective institutional series.

OBJECTIVE: Chordomas are a rare and relatively slow-growing malignancy of notochordal origin with a nearly 50% recurrence rate. Chordomas of the cervical spine are particularly challenging tumors given surrounding vital anatomical structures. Although standard in other areas of the spine, en bloc resection of cervical chordomas is exceedingly difficult and carries the risk of significant postoperative morbidity. Here, the authors present their institutional experience with 13 patients treated with a structure-sparing radical resection and adjuvant radiation for cervical chordomas. METHODS: Records of the standing senior author and institutional database of spinal surgeries were retrospectively reviewed for surgically managed cervical and high thoracic chordomas between 1997 and 2022. Chordomas whose epicenter was cervical but touched the clivus or had extension to the thoracic spine were included in this series. Clinical and operative data were gathered and analyzed for the index surgery and any revisions needed. Outcome metrics such as recurrence rates, complication rates, functional status, progression-free interval (PFI) and overall survival (OS) were evaluated. RESULTS: The median patient age at diagnosis was 57 (range 32-80) years. The median modified Rankin Scale (mRS) score at the time of presentation was 1 (range 0-4). Approximately 40% of tumors were located in the upper cervical spine (occiput-C2). The median time from diagnosis to surgery was 74.5 (range 10-483) days. Gross-total resection was achieved in just under 40% of patients. All patients received adjuvant radiotherapy. The mean duration of follow-up was 4.09 years, with a mean PFI of 3.80 (range 1.16-13.1) years. Five patients experienced recurrence (38.5%). The mean OS was 3.44 years. Three patients died during the follow-up period; 2 due to disease progression and 1 died in the immediate postoperative period. One patient was lost to follow-up. A significant positive relationship was identified between high cervical tumor location and disease recurrence (p = 0.021). CONCLUSIONS: While en bloc resection is appropriate and feasible for tumors in the sacral spine, the cervical region poses a significant technical challenge and is associated with increased postoperative morbidity. Radical resection may allow for achievement of negative operative margins and, along with sparing postoperative morbidity following resection of cervical chordomas, maintaining a similar rate of recurrence when compared with en bloc resection while preserving quality of life.

Predictors of clinical and structural outcomes after surgery for spinal nerve sheath tumor resection: a retrospective analysis.

OBJECTIVE: Resection of spinal nerve sheath tumors (SNSTs) typically necessitates laminectomy, often with facetectomy, for adequate exposure of tumor. While removal of bone affords a greater operative window and extent of resection, it places the patient at greater risk for spinal instability. Although studies have identified risk factors for fusion at the time of tumor resection, there has yet to be a study assessing long-term stability following SNST resection. In this study, the authors sought to identify preoperative and operative risk factors that predispose to long-term spinal instability and investigate clinical variables associated with greater risk for subsequent fusion in the time following initial SNST resection. METHODS: An institutional registry of spinal surgeries was queried at a single institution over a 20-year period. Demographic, clinical, and operative variables were recorded retrospectively and investigated for predictive value of several postoperative sequelae. RESULTS: A total of 122 SNST cases among 112 patients were included. At a mean follow-up time of 27.7 months, patients with a history of neurofibromatosis type 2 (NF2) (p = 0.014) and those who had undergone a laminectomy of ≥ 4 levels at the time of initial SNST resection (p = 0.028) were more likely to present with some degree of structural abnormality or neurological deficit following their initial surgery. The presence of facetectomy, degree of laminectomy, and level of spinal surgery were not found to be predictors of future instability. Ultimately, there was no significant predictor for true spinal instability following index surgery without fusion. A secondary analysis showed that an entirely extradural location (p = 0.044) and facetectomy at index surgery (p = 0.012) were predictive of fusion being performed at the time of tumor resection. Four of the 112 patients required fusion after their index SNST resection, 3 of whom underwent fusion for instability at the level of the index surgery. No variables were identified as predictive for future instrumentation. CONCLUSIONS: Ultimately, the authors conclude that resection of SNSTs does not always necessitate fusion, and good outcomes can be obtained with motion-preserving techniques and minimizing facetectomy when possible. Patients with a history of NF2 and those with SNSTs that required ≥ 4-level laminectomy were more likely to exhibit some degree of structural abnormality and/or neurological deficit localized to the index level defined as either new or worsening spinal instability and/or new or worsening neurological deficit at last follow-up; however, no variable was found to be predictive of true spinal instability. Furthermore, a complete facetectomy at initial SNST resection and entirely extradural tumor location were noted to be associated with fusion at index surgery. Lastly, the authors were unable to identify a clinical predictor for future instrumentation.

Exploring the Landscape of Machine Learning Applications in Neurosurgery: A Bibliometric Analysis and Narrative Review of Trends and Future Directions.

BACKGROUND: The field of neurosurgery has consistently represented an area of innovation and integration of technology since its inception. As such, machine learning (ML) has found its way into applications within neurosurgery relatively rapidly. Through this bibliometric review and cluster analysis, we seek to identify trends and emerging applications of ML within neurosurgery. METHODS: A bibliometric analysis was carried out in the Web of Science database on publications from January 2000 to March 2023. The full data set of the 200 most cited publications including title, author information, journal, citation count, keywords, and abstracts for each publication was evaluated in CiteSpace. CiteSpace was used to elucidate publication characteristics, trends, and topic clusters via collaborate network analysis using the Kamada-Kawai algorithm. RESULTS: The 25 most cited titles were included in our analysis. Harvard University and its affiliates represented the top institution, contributing nearly 25% of publications in the literature. WORLD NEUROSURGERY was the journal with the highest net citation count of 747 (29%). Collaborative network analysis generated 12 unique clusters, the largest of which was machine learning, followed by feature importance and deep brain stimulation. CONCLUSION: This review highlights the most impactful articles pertaining to ML in the field of neurosurgery. ML has been applied into several sub-specialties within neurosurgery to optimize patient care, with special attention to outcome predictors, patient selection, and surgical decision making.

Tandem Reconstruction of the Femoral Diaphysis Using an Intercalary Prosthesis and a Fibular Free Flap.

BACKGROUND: Femoral diaphyseal reconstructions with metal prostheses have mediocre results because of high mechanical forces that result in eventual implant failure. Biological alternatives require prolonged restrictions on weight-bearing and have high rates of infection, nonunion, and fracture. A novel method of utilizing a vascularized fibula in combination with an intercalary prosthesis was developed to complement the immediate stability of the prosthesis with the long-term biological fixation of a vascularized fibular graft. METHODS: A prospectively maintained database was retrospectively reviewed to identify patients who underwent reconstruction of an oncological intercalary femoral defect using an intercalary prosthesis and an inline fibular free flap (FFF). They were compared with patients who underwent femoral reconstruction using an intercalary allograft and an FFF. RESULTS: Femoral reconstruction with an intercalary metal prosthesis and an FFF was performed in 8 patients, and reconstruction with an allograft and an FFF was performed in 16 patients. The mean follow-up was 5.3 years and 8.5 years, respectively (p = 0.02). In the bioprosthetic group, radiographic union of the fibula occurred in 7 (88%) of 8 patients, whereas in the allograft group, 13 (81%) of 16 patients had allograft union (p = 1.00) and all 16 patients had fibular union (p = 0.33). The mean time to fibular union in the bioprosthetic group was 9.0 months, whereas in the allograft group, the mean time to allograft union was 15.3 months (p = 0.03) and the mean time to fibular union was 12.5 months (p = 0.42). Unrestricted weight-bearing occurred at a mean of 3.7 months in the prosthesis group and 16.5 months in the allograft group (p < 0.01). Complications were observed in 2 (25%) of 8 patients in the prosthesis group and in 13 (81%) of 16 patients in the allograft group (p = 0.02). Neither chemotherapy nor radiation affected fibular or allograft union rates. Musculoskeletal Tumor Society scores did not differ significantly between the groups (mean, 26 versus 28; p = 0.10). CONCLUSIONS: Bioprosthetic intercalary femoral reconstruction with a metal prosthesis and an FFF resulted in earlier weight-bearing, a shorter time to union, fewer operations needed for union, and lower complication rates than reconstruction with an allograft and an FFF. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Same-day discharge after craniotomy for brain tumor resection: enhancing patient selection through a prognostic scoring system.

OBJECTIVE: Neurosurgery, among other surgical fields, is amid a shift in patient management with enhanced recovery and same-day discharge (SDD) protocols slowly becoming more popular and feasible. While such protocols reduce the risk of nosocomial complications and improve patient satisfaction, appropriate patient selection remains an area of debate. The authors aimed to better quantify selection criteria through a prospective follow-up study of patients undergoing brain tumor resection with SDD. METHODS: Three arms of analysis were carried out. First, clinical data of SDD patients were prospectively collected between August 2021 and August 2022. In parallel, a retrospective analysis of patients who qualified for SDD but were excluded at surgeon clinical discretion over the same period was performed. Third, a comparative analysis of the pilot and follow-up studies was done from which a clinical scoring system for patient selection was derived. RESULTS: Over the duration of the study, 31 of 334 patients were selected for SDD while 59 qualified for SDD by previously defined criteria but were not selected at the surgeon's discretion. There was no difference in outcomes between the two groups, and there were no postoperative complications among the SDD group within 30 days of surgery. Preoperative clinical characteristics found to be significantly different between the two cohorts (left-sided lesion, extra-axial pathology, prior treatment of brain tumor, and tumor volume ≤ 11.75 cm3) were included in a predictive scoring system for successful SDD. The scoring system was found to significantly predict high or low likelihood for successful SDD when tested on the mixed prospective cohort. CONCLUSIONS: This study provides a straightforward clinical scoring system for appropriate selection of candidates for SDD after craniotomy for brain tumor resection. This clinical tool aims to aid clinicians in appropriate admission course selection and builds on the growing literature surrounding same-day and outpatient cranial neurosurgery.

Responsive neurostimulation for treatment of pediatric refractory epilepsy: A pooled analysis of the literature.

BACKGROUND: Drug-resistant epilepsy (DRE) is a complex medical condition often requiring resective surgery and/or some form of neurostimulation. In recent years responsive neurostimulation (RNS) has shown promising results in adult DRE, however there is a paucity of information regarding outcomes of RNS among pediatric patients treated with DRE. In this individual patient data meta-analysis (IPDMA) we seek to elucidate the effects RNS has on the pediatric population. METHODS: Literature regarding management of pediatric DRE via RNS was reviewed in accordance with individual patient data meta-analysis guidelines. Four databases were searched with keywords ((Responsive neurostimulation) AND (epilepsy)) through December of 2022. From 1624 retrieved full text studies, 15 were ultimately included affording a pool of 98 individual participants. RESULTS: The median age at implantation was 14 years (n = 95) with 42% of patients having undergone prior resective epilepsy surgery, 18% with prior vagus nerve stimulation (VNS), and 1% with prior RNS. At a median follow up time 12 months, median percent seizure reduction was 75% with 57% of patients achieving Engel Class < 2 outcome, 9.7% of which achieved seizure freedom. We report a postoperative complication rate of 8.4%, half of which were device-related infections. Magnetic resonance imaging (MRI)-negative cases were negatively associated with magnitude of seizure reduction, and direct targeting techniques were associated with stronger treatment response when compared to other methods. CONCLUSIONS: This review suggests RNS to be an effective treatment modality for pediatric patients with a postoperative complication rate comparable to that of RNS in adults. Investigation of prognostic clinical variables should be undertaken to augment patient selection. Last, multi-institutional prospective study of long-term effects of RNS on pediatric patients would stand to benefit clinicians in the management of pediatric DRE.

Two-stage radiosurgery for large brain metastases: a systematic review and meta-analysis of clinical outcomes.

OBJECTIVE: Brain metastases (BMs) are the most common intracranial tumors. In several cases, they present as large masses, which are related to a worse prognosis and more complex therapeutic alternatives. Staged radiosurgery is reported to achieve local control with minimal radiation-related adverse events in BMs. However, no methodological consensus has been achieved in its use for large brain metastases (LBMs; > 2 cm). Therefore, the authors aimed to determine the effectiveness and safety of 2-stage Gamma Knife radiosurgery (GKRS) for LBMs, in order to optimize patients' postoperative course. METHODS: A systematic review of available literature was run in PubMed/MEDLINE, Scopus, Web of Science, Cochrane (OvidSP), and Google Scholar for works published up to December 14, 2022. Nonrandomized clinical trials, case series, and cohort studies were included. The risk of bias was assessed using the Risk of Bias in Nonrandomized Studies-of Interventions (ROBINS-I) and Joanna Briggs Institute tools. Pooled mean difference and rates estimates were calculated by a random-effects model meta-analysis. The degree of heterogeneity was expressed using the I2 statistic. A subgroup analysis was performed. Ultimately, the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment. RESULTS: Fourteen studies met the eligibility criteria (cohorts, case series, and nonrandomized clinical trials), including 958 patients. A total pooled mean volume reduction of 6.27 cm3 (95% CI 5.67-6.88 cm3) and 54.36% (95% CI 39.92%-68.79%) after 2-stage GKRS was reported. Pooled rates of complete response (44.63%; 95% CI 26.50%-64.31%), neurological mortality (16.19%; 95% CI 7.68%-30.98%), and all-cause mortality (47.92%; 95% CI 28.04%-68.49%) were calculated. Overall certainty of evidence ranged from very low to moderate. CONCLUSIONS: Two-stage GKRS is an effective and safe approach for the treatment of LBMs. Nevertheless, the lack of available literature and the weak methodological approaches used determine a low to very low certainty of evidence and cannot provide robust evidence to recommend this intervention. Therefore, it is necessary to conduct higher-quality primary studies.

Ancient Schwannoma Presenting at the Cauda Equina: A Report of a Rare Case.

Ancient schwannoma is an uncommon variant of schwannoma. While many reports have presented defining histologic and clinical features of ancient schwannoma, there are only a very few cases in the literature, to our knowledge, of ancient schwannoma presenting at the cauda equina. The current report of ancient schwannoma presenting at the cauda equina adds to the literature and discusses the identification of specific histologic characteristics, the role of conservative medical management, surgical resection, and prognostication in this select subset of patients.

Towards the definition of progressive disease in brain metastasis treated with laser ablation: an evidence-based study.

PURPOSE: The postoperative period after laser interstitial thermal therapy (LITT) is marked by a temporary increase in volume, which can impact the accuracy of radiographic assessment. The current criteria for progressive disease (PD) suggest that a 20% increase in size of brain metastasis (BM) assessed in 6-12 weeks intervals should be considered as local progression (LP). However, there is no agreement on how LP should be defined in this context. In this study, we aimed to statistically analyze which tumor volume variations were associated with LP. METHODS: We analyzed 40 BM that underwent LITT between 2013 and 2022. For this study, LP was defined following radiographic features. A ROC curve was generated to evaluate volume change as a predictor of LP and find the optimal cutoff point. A logistic regression analysis and Kaplan Meier curves were performed to assess the impact of various clinical variables on LP. RESULTS: Out of 40 lesions, 12 (30%) had LP. An increase in volume of 25.6% from baseline within 120-180 days after LITT presented a 70% sensitivity and 88.9% specificity for predicting LP (AUC: 0.78, p = 0.041). The multivariate analysis showed a 25% increase in volume between 120 and 180 days as a negative predictive factor (p = 0.02). Volumetric changes within 60-90 days after LITT did not predict LP (AUC: 0.57; p = 0.61). CONCLUSION: Volume changes within the first 120 days after the procedure are not independent indicators of LP of metastatic brain lesions treated with LITT.

Thalamic responsive neurostimulation for the treatment of refractory epilepsy: an individual patient data meta-analysis.

OBJECTIVE: In recent years, the treatment of drug-resistant epilepsy (DRE) has made greater use of surgery and expanded options for neurostimulation or neuromodulation. Up to this point, responsive neurostimulation (RNS) has been very promising but has mainly used only the cortex as a target. In this individual patient data meta-analysis (IPDMA), the authors sought to establish if a novel RNS target, the thalamus, can be used to treat DRE. METHODS: The literature regarding the management of DRE by targeting the thalamus with RNS was reviewed per IPDMA guidelines. Five databases were searched with keywords [((Responsive neurostimulation) OR (RNS)) AND ((thalamus) OR (thalamic) OR (Deep-seated) OR (Diencephalon) OR (limbic))] in March 2022. RESULTS: The median (interquartile range) age at implantation was 17 (13.5-27.5) years (n = 42) with an epilepsy duration of 12.1 (5.8-15.3) years. In total, 52.4% of patients had previously undergone epilepsy surgery, 28.6% had prior vagus nerve stimulation, and 2.4% had prior RNS. The median preimplant seizure frequency was 12 per week. The median seizure reduction at last follow-up was 73%. No study in this IPDMA reported complications, although 7 cases (16.3%) did require reoperation. Behavioral improvements and reduced antiepileptic drug dose or quantity were reported for 80% and 28.6% of patients, respectively. CONCLUSIONS: This review indicates that thalamic RNS may be safe and effective for treating DRE. Long-term and controlled studies on thalamic RNS for DRE would further elucidate this technique's potential benefits and complications and help guide clinical judgment in the management of DRE.

Development of an enhanced recovery protocol after laser ablation surgery protocol: a preliminary analysis.

Background: Enhanced recovery after surgery (ERAS) programs are a model of care that aim to improve patient outcomes, reduce complications, and facilitate recovery while reducing healthcare-associated costs and admission length. While such programs have been developed in other surgical subspecialties, there have yet to be guidelines published specifically for laser interstitial thermal therapy (LITT). Here we describe the first multidisciplinary ERAS preliminary protocol for LITT for the treatment of brain tumors. Methods: Between the years 2013 and 2021, 184 adult patients consecutively treated with LITT at our single institution were retrospectively analyzed. During this time, a series of pre, intra, and postoperative adjustments were made to the admission course and surgical/anesthesia workflow with the goal of improving recovery and admission length. Results: The mean age at surgery was 60.7 years with a median preoperative Karnofsky performance score of 90 ± 13. Lesions were most commonly metastases (50%) and high-grade gliomas (37%). The mean length of stay was 2.4 days, with the average patient being discharged 1.2 days after surgery. There was an overall readmission rate of 8.7% with a LITT-specific readmission rate of 2.2%. Three of 184 patients required repeat intervention in the perioperative period, and there was one perioperative mortality. Conclusions: This preliminary study shows the proposed LITT ERAS protocol to be a safe means of discharging patients on postoperative day 1 while preserving outcomes. Although future prospective work is needed to validate this protocol, results show the ERAS approach to be promising for LITT.

Trends in Leadership Among Neurosurgical Oncology Fellowships.

OBJECTIVE: To examine current neurosurgical oncology leadership trends and provide a guide for those interested in obtaining fellowship directorship, we investigated fellowship director (FD) demographic, educational, and leadership characteristics. METHODS: The American Association of Neurological Surgeons Academic Fellowship Directory and Committee on Advanced Subspecialty Training websites were reviewed for current U.S. program FDs for which data were collected using online resources and surveys. RESULTS: In total, 23 FDs (20 male and 3 female) were represented whose mean age was 52.4 years (standard deviation = 8.7). Our analysis found 65% of current neurosurgical oncology FDs to be singularly trained in neurosurgical oncology, with 8.7% possessing multiple fellowships and 34.8% possessing additional degrees. Fellowship programs producing the most FDs were University of Texas MD Anderson (4), Memorial Sloan Kettering (3), and University of Miami (2). FDs possessed an average of 148 publications, 6423 citations, and an h-index of 33.9. H-index had a high-positive correlation with age and time from residency graduation but not duration of FD appointment. Among survey respondents, 91.7% reported membership and 75% reported leadership positions among national academic societies, whereas 66.7% reported holding journal-editorial positions. The mean age of FD appointment was 46.8 years, with a mean time from fellowship completion to FD appointment of 10.0 years. CONCLUSIONS: Through the characterization of current leaders in the field, we provide valuable information with regards to training location trends, research productivity goals, career timelines, and target journal/national academic society involvement worth consideration among young trainees when making career decisions and plans.

Lymphatic Microsurgical Preventive Healing Approach for the Primary Prevention of Lymphedema: A 4-Year Follow-Up.

BACKGROUND: Axillary lymph node dissection (ALND) remains the leading cause of lymphedema nationally, and there is still no cure for the disease. The lymphatic microsurgical preventive healing approach (LYMPHA) is a promising option for lymphedema prophylaxis in patients undergoing ALND, but long-term outcomes of the LYMPHA are not well established. METHODS: The authors conducted a retrospective review of patients undergoing ALND at their center from November of 2012 to November of 2016 and assembled two cohorts, those who received the LYMPHA and those who did not (non-LYMPHA). Patient data were collected to evaluate lymphedema risk and long-term lymphedema incidence of each group. RESULTS: Forty-five women were included in both our LYMPHA and non-LYMPHA cohorts. Mean body mass index (27.7 kg/m2 versus 29.9 kg/m2; P = 0.15) and radiation therapy rates (60.0% versus 68.9%; P = 0.51) did not differ between groups. Non-LYMPHA patients underwent complete mastectomy more frequently than LYMPHA patients (97.8% versus 77.8%; P = 0.007), but had a similar number of nodes removed during ALND (14.4 versus 15.8; P = 0.32). Median follow-up time was greater than 4 years for both LYMPHA and non-LYMPHA groups (57.0 months versus 63.0 months; P = 0.07). Overall, lymphedema incidence was 31.1% in the LYMPHA group and 33.3% in the non-LYMPHA group (P > 0.99). No significant differences in lymphedema incidences were observed between the LYMPHA and non-LYMPHA groups for patients with obesity, patients who received radiation therapy, or patients with obesity who also received radiation therapy (P > 0.05 for all subgroups). CONCLUSIONS: The LYMPHA may not prevent lymphedema long-term in patients who undergo ALND. More long-term studies are needed to determine the true potential of the procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Safety of the utilization of telemedicine for brain tumor neurosurgery follow-up.

Background: There is a need to evaluate the outcomes of patients who underwent brain tumor surgery with subsequent telemedicine or in-person follow-up during the COVID-19 pandemic. Methods: We retrospectively included all patients who underwent surgery for brain tumor resection by a single neurosurgeon at our Institution from the beginning of the COVID-19 pandemic restrictions (March 2020) to August 2021. Outcomes were assessed by stratifying the patients using their preference for follow-up method (telemedicine or in-person). Results: Three-hundred and eighteen (318) brain tumor patients who were included. The follow-up method of choice was telemedicine (TM) in 185 patients (58.17%), and in-person (IP) consults in 133 patients. We found that patients followed by TM lived significantly farther, with a median of 36.34 miles, compared to a median of 22.23 miles in the IP cohort (P = .0025). We found no statistical difference between the TM and the IP group, when comparing visits to the emergency department (ED) within 30 days after surgery (7.3% vs 6.01%, P = .72). Readmission rates, wound infections, and 30-day mortality were similar in both cohorts. These findings were also consistent after matching cohorts using a propensity score. The percentage of telemedicine follow-up consults was higher in the first semester (73.17%) of the COVID-19 pandemic, compared to the second (46.21%), and third semesters (47.86%). Conclusions: Telehealth follow-up alternatives may be safely offered to patients after brain tumor surgery, thereby reducing patient burden in those with longer distances to the hospital or special situations as the COVID-19 pandemic.

Surgical Approaches to Thalamic Gliomas: A Systematic Review.

BACKGROUND: Adult thalamic gliomas (ATGs) present a surgical challenge given their depth and proximity to eloquent brain regions. Choosing a surgical approach relies on different clinical variables such as anatomical location and size of the tumor. However, conclusive data regarding how these variables influence the balance between extent of resection and complications are lacking. We aim to systematically review the literature to describe the current surgical outcomes of ATG and to provide tools that may improve the decision-making process. METHODS: Literature regarding the surgical management of ATG patients was reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Four databases were queried and a description of clinical characteristics and survival analysis were performed. An individual patient data analysis was conducted when feasible. RESULTS: A total of 462 patients were included from 13 studies. The mean age was 39.8 years with a median preoperative Karnofsky performance scale of 70. The lateral approaches were most frequently used (74.9%), followed by the interhemispheric (24.2%). Gross total and subtotal/partial resections were achieved in 81%, and 19% of all cases, respectively. New permanent neurological deficits were observed in 51/433 patients (11.8%). individual patient data was pooled from 5 studies (n = 71). In the multivariate analysis, tumors located within the posterior thalamus had worse median overall survival compared to anterior gliomas (14.5 vs. 27 months, P = 0.003). CONCLUSIONS: Surgical resection of ATGs can increase survival but at the risk of operative morbidity. Knowing which factors impact survival may allow neurosurgeons to propose a more evidence-based treatment to their patients.

Concurrent intraventricular intracranial myxoid mesenchymal tumor and ependymoma in a long-term Ewing sarcoma survivor.

Intracranial myxoid mesenchymal tumor, FET::CREB fusion positive is a rare, recently described central nervous system neoplasm. It is characterized by EWSR1::CREB family transcription factor fusion, typically arises in children and adolescents, and is locally aggressive even after gross total resection. Currently, there are little data available to guide management and gauge long-term prognosis. Furthermore, there have been no reports of these lesions occurring simultaneously with other intracranial neoplasms or in patients with a history of malignancy. Here we describe the first case of a very unusual patient with intracranial myxoid mesenchymal tumor of the right lateral ventricle with a concurrent fourth ventricular ependymoma who had a remote history of Ewing sarcoma of the right fibula.